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"content": "A 72-year-old white Caucasian man, without prior history of heart disease was admitted with symptoms of weakness, dizziness and chest discomfort for several hours. Physical examination revealed low blood pressure (85/50 mmHg) and a weak, regular and rapid pulse. The electrocardiogram (ECG) showed a wide-complex tachycardia with LBBB morphology and left axis deviation. Because of continuing hemodynamic instability, the patient was cardioverted to sinus rhythm with a single 300 J shock.\nThe ECG during the episode of the tachycardia was consistent with sustained VT of right ventricular origin. Post-cardioversion ECG showed negative T-waves at the inferior and precordial leads with a QRS duration of 110 ms and the presence of an epsilon wave in V1 (Figure ).\nChemistries were normal with the exception of troponin I which was positive. The patient was subsequently started on metoprolol. Continuous ECG monitoring revealed multiple episodes of non-sustained VT. Cardiac ultrasound examination showed a normal left ventricle and a slightly enlarged right ventricle with local dyskinesia and diastolic bulging of the free wall (Figure ).\nAs a diagnosis of ARVC was most likely, the patient underwent simultaneous cardiac catheterization and electrophysiological study. His coronary arteries and left ventricle were normal. Right ventriculography in the right anterior oblique view confirmed the local hypokinesia of the free wall with diastolic bulging. During the electrophysiological study, a sustained VT was provoked with identical morphology to the one on admission. The VT responded to antitachycardia pacing and the defibrillation threshold was 17 J.\nA magnetic resonance imaging (MRI) scan that followed revealed diffuse areas of fat tissue at the right ventricular wall especially localized at the free and lateral segments, while multiple small aneurysms were also present (Figure ). Right ventricular ejection fraction was 30%. Left ventricular free wall ",
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"content": " and intraventricular septum were free of disease. Finally, a <|endoftext|>",
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"content": "A 52 years old man who presented with an incidental finding of an aortic regurgitant murmur underwent further investigations which reveal a dilated ascending aorta (5.1 cm at its widest point) and associated aortic regurgitation. There was no other significant past medical history. He subsequently underwent aortic valve replacement with a mechanical prosthesis and also ascending aorta replacement with a PTFE interposition tube graft. The thymic fat was divided in the midline. Cardiopulmonary bypass was established with a single two-stage venous cannula and aortic return was to left ",
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"content": " femoral artery. There was no intra-operative complication and <|endoftext|>",
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"content": "We present a case of a 50-year-old Caucasian male who presented to the emergency department with complaints of lower abdominal pain, fever and sweating. On examination, the patient had tendernes",
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"content": " s to palpation in <|endoftext|>",
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"content": "A 72 year old man was admitted to our department with a nine month history of gradually enlarging mass in the volar aspect of the hypothenar area of his left hand. The patient reported that the size of the mass had been increasing during the past 3 months. As far as the rest medical record is concerned he was under medication for diabetes mellitus type 2 with metformin and he had undergone an operation for colorectal malignancy 6 years before presentation. He had no previous hand injury. The patient experienced persistent pain and altered sensation on the ulnar side of the hand, accompanied with progressively diminishing grip strength. Physical examination revealed a small, mobile, and painless palpable mass in the hypothenar area. The skin overlying the mass was normal. The range of motion of the finger joints was not restricted and there was no vascular impairment.\nLaboratory exams were within normal limits and radiographs of the hand demonstrated no osseous involvement or radio-opaque lesion. Ultrasound (U/S) examination revealed a solid, hypoechoic and homogeneous tumor with capsule in the ulnovolar aspect of the left hand (). Magnetic Resonance Imaging (MRI) indicated a multi-lobulated mass, located in the volar aspect of the fourth web space of the hand, not infiltrating adjacent structures or having bony involvement and bone edema (). No biopsy was performed preoperatively, since all radiological studies suggested a benign tumor.\nThe patient was operated under axillary nerve block. Using a Brunner incision volarly the skin and the palmar fascia were divided carefully. The neurovascular bundles were identified and protected. The mass was removed en block with clear margins. The gross specimen consisted of a lobulated, well-circumscribed, gelatinous mass ().\nThe histopathology of the specimen revealed () uniform, cytologically bland spindle-shaped cells with eosinophilic cytoplasm separated by abundant extracellular myxoid stroma containing very sparse capillary – sized blood vess",
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"content": " els. After the last follow up, 12 months following the excision, the ring <|endoftext|>",
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"content": "This case corresponds to a 16-year-old Caucasian male, who was diagnosed with PGC at the age of 5 and was brother of case 2. He was on medical treatment (one drug) for elevated IOP from age 5. At presentation in HCSC, an enlarged corneal diameter was the only sign detected. At the age of 16 a goniotomy in the OS was performed because of poor IOP control despite being on three topical glaucoma medications. Five months later, a trabeculectomy was required in the OS, achieving IOP control since then without medication. The IOP in the OD has been controlled up to the present with three topical glaucoma medications, and no previous surgical procedures were required.\nThe trabeculectomy from the OS of this patient contained two pieces of tissue, one corresponding to a part of the sclera and another containing the rest of the sclera, the SC and the TM",
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"content": " . In semithin sections, we observed a SC with an open lumen, a quite compact CTM, and an UTM with well-developed intertrabecular spaces “”. In either pieces of sclera, we found no collector channels. The TEM revealed that most of the SC endothelial cells had disappeared with only debris of necrotic cells being observed “”. The JCT was composed of alternating layers of abundant ground substance, elastic-like fibers, fibrillary collagen and necrotic stellate cells “”. The CTM was difficult to recognize because the tissue was quite disorganized “”. In some areas the trabecular beams were separate and the zones that would correspond with the inter-trabecular spaces were occupied by the remains of necrotic cells and by collagen that had been detached from the trabeculae “”. In other areas the trabecular beams were fused, the boundary between them being recognized by the presence of necrotic cells debris “”. The trabecular beam had basal membranes, many elastic-like fibers, fibrillary collagen and abundant ground substance � <|endoftext|>",
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"content": "A 52-year-old Caucasian woman presented to the emergency department with a 3-day history of severe right leg pain associated with a cold and pale foot. Prior to this episode, she described a two-month history of mild intermittent claudication.",
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"content": " There was no history of trauma. Pertinent past medical history included hypertension, a significant smoking history of approximately <|endoftext|>",
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"content": "A 28-year-old man presented to the emergen",
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"content": " cy department of our hospital complaining of sudden painful loss of vision in the <|endoftext|>",
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"content": "A 48-year-old, 48 kg, 154-cm tall woman, ASA physical status II, posted for total abdominal hysterectomy and bilateral salpingo-oophorectomy, was scheduled for a combination of continuous lumbar epidural analgesia and general anaesthetic. The surgery was indicated for management of an ovarian tumour. She had a history of some psychiatric illness a few years back and was on medications, which were later discontinued, but details of the same could not be obtained owing to poor documentation. During location of the epidural space, the initial attempt resulted in a dural puncture, following which the epidural space was located at the imme",
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"content": " diate upper spinous interspace and anaesthesia proceeded uneventfully with endotracheal intubation. She was extubated on table, Inj morphine <|endoftext|>",
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"content": "A 49-year-old previously healthy woman presented to a local emergency department because of recurrent fatigue, dyspnoea, and chest pain within the last three weeks. She described a “flu-like” upper respiratory infection for the past month that progressively worsened to these specific symptoms. The echocardiographic evaluation showed ejection fraction (EF) about 10% with biventricular failure. Despite pathologic ECG and highly elevated cardiac troponin, urgent cardiac catheterization detected only mild coronary sclerosis. During this procedure she progressed to circulatory collapse with the need for highly inotropic support and mechanical ventilation. For higher level of care the lady was transferred to our institution.\nDue to rapid aggravation of her condition while admission at our ICU, we initiated intraaortic balloon pump (IABP) implantation via the right femoral artery and venoarterial Extracorporeal Membrane Oxygenation (ECMO) implantation through the right femoral vein and right axillary artery. Despite maximum hemodynamic support, the heart showed no evidence of recovery. Furthermore the lady progressed to multiple organ failure including highly elevated lactate level, acute renal failure, and hepatic insufficiency. Our Heart Team decided on urgent biventricular CentriMag (Levitronix, Waltham, MA) implantation to decompress and support both ventricles.\nThrough a median sternotomy the right atrium and aorta were cannulated and the patient was transferred from ECMO to cardiopulmonary bypass (CPB). A left ventricular 23 F ",
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"content": " cannula and a 22 F right atrial p-VAD cannula were placed for biventricular outflow into the CentriMag pumps. The left apex cannulation was chosen for maximum flow and complete left ventricular decompression. For return flow to pulmonary and systemic circulation the pulmonary artery and the ascending aorta were anastomosed with two 18 F sealed inflow cannulas. The patient was then weaned from CPB to BVAD support. The ECMO cannulas were removed and the femoral vessels repaired. With moderate inotropic support the patient was administrated to our ICU (). Intravenous continuous heparine was introduced to achieve an activating <|endoftext|>",
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"content": "A 39-year-old man presented to the outpatient clinic with sudden vision loss that had started 15 days previously. His visual acuity in both eyes was at the level of hand motion. Pupillary light",
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"content": " reflexes and eye movements were normal. Anterior segment biomicroscopy findings and intraocular pressure <|endoftext|>",
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"content": "A 33-year-old female patient who was still breastfeeding 10 months after her first natural delivery visited our outpatient clinic because of a left intertrochanteric fracture caused by falling from standing height. Before her pregnancy, the patient had no hypertension, diabetes mellitus, or other chronic diseases. She had no history of long-term drug use, smoking, or alcohol intake. She had not had any operations, did not suffer from hip or femur trauma, and had no family history of osteoporosis or hip fracture. During her pregnancy, the patient had no preeclampsia, eclampsia, gestational hyperthyroidism, or other metabolic diseases. She had no history of chronic diarrhea and never used glucocorticoids, heparin, or other drugs. Calcium 600 mg and vitamin D3 700 IU were supplemented every day during pregnancy, but she discontinued taking calcium and vitamin D after delivery. The patient had never complained about lower back or transient hip pain or a decrease in self-awareness of height during pregnancy and lactation. The patient experienced pain in the left hip after a fall, and could not stand on her left leg. At a physical examination, shortening deformity at the left leg was found, the range of motion in the left hip was restricted because of pain, and there was localized tenderness with palpation on the left hip. Percussion pain in the left lower limb was positive, but there was no tenderness in the spinal process in the thoracolumbar region and paravertebral muscles. Hip radiography () showed a left intertrochanteric fracture. Although the patient never complained about low back pain, magnetic resonance imaging of the thoracic and lumbar spine identified a new compression fracture in the L1 vertebra with marrow edema (). Laboratory test results are shown in . Serum calcium and parathyroid hormone concentrations were in the normal range, and 25-hydroxyvitamin D3 and albumin concentrations were low. BMD was measured",
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"content": " with DXA, which showed a reduction in density in the hip <|endoftext|>",
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"content": "A 43-year-old male experienced a dull pain at the right back of his head. The headache thereafter evolved into right orbital pain. The patient subsequently developed gradually progressive diplopia. Cerebral magnetic resonance imaging (MRI) showed a mass lesion in the right clivus that was suspected to be a meningioma. The patient was admitted for surgery. A neurological examination showed no abnormalities other than right abducent nerve paralysis. Cerebral computed tomography (CT) revealed a tumor with homogenous enhancement which came in contact with the petrous bone from the right clivus. However, no osseous proliferative change was observed. Cerebral MRI revealed a mass appearing as homogeneously hypointense on T1, and hyperintense on T2-weighted images. T1-weighted MRI with gadolinium showed a heterogeneously enhanced mass in the petrous bone from the right clivus ().\nThe patient underwent a resection of the mass via a left suboccipital craniotomy. Oral intubation was done with I.D 7.5 spiral tube using the Macintosh laryngoscope blade. Intubation was easy. The endotracheal tube was secured at a depth of 23 cm with a bite block and adhesive tape. The patient was then placed in the left park bench position, and the head was fixed with neck flexion. There was no excessive cervical flexion. Surgery was performed via the left lateral suboccipital approach. The lesion was not clearly visible, so hypertrophic dura mater was approved. There wa",
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"content": " s no apparent <|endoftext|>",
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"content": "A 32-year-old man was admitted to our emergency department in a coma. He was found in cardiac arrest following a suicide attempt by hanging himself. After 6 minutes of CPR, his vital signs returned within the normal ranges. On arrival at the emergency department, he was still in a coma and brain computed tomography (CT) showed no abnormalities ().\nOn day 3 of hospitalization, he developed a generalized seizure in the intensive care unit after discontinuing an intravenous infusion of midazolam (7 mg per hour) and fentanyl (100 µg). Then, myoclonic movements were continuously observed over the entire body, including the face. At that time, the myoclonic movements were considered as generalized myoclonus secondary to hypoxic brain insult and these were empirically treated with sodium valproate. However, the myoclonic jerks were not controlled after increasing the dose of sodium valproate to 1,500 mg and phenytoin to 1,000 mg daily. The myoclonic jerks ceased with a bolus ",
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"content": " injection of midazolam or Norcuron, but the effect was transient. On day 6 of hospitalization, an EEG was performed and <|endoftext|>",
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"content": "A 38-year-old female was admitted in the gynecology outpatient's clinic due to secondary infertility. She was Gesta I Para I, with one previous uneventful pregnancy and a cesarean section 7 years before. She had hypothyroidism and was medicated with levothyroxine 150 μg. As soon as she left the combined pill in order to conceive, she started complaining of severe dysmenorrhea (pain score: 8/10). At physical examination, a hard and painful nodule was palpable at midline, under the cesarean section scar. She had a nonmobile uterus. A painful hard mass was palpable at rectal digital examination, 3 cm away from the anus.\nAbdominal wall soft tissue ultrasound revealed a nodule of heterogeneous echogenicity with 41 mm × 34 mm × 17 mm located medially at the level of the rectus abdominis muscle, under the cesarean section scar [Figures -]. Abdominal magnetic resonance imaging confirmed the presence of a nodule with 4.9 cm × 3.8 cm × 2.0 cm on the rectus abdominis muscle and its fascia [Figures and ]. Pelvic transvaginal ultrasound revealed normal uterus and right adnexa and a cyst at the left ovary with 30 mm × 26 mm, with no septa or solid components and with ground glass echogenicity.\nThe patient was submitted to laparotomy. During surgery, a hard median nodule with 5 cm of length was found located in the rectus abdominis muscle and its fascia [Figures and ]. Pelvic anatomy was completely distorted with several adhesions between the uterus, the adnexa, colon, and pelvic wall. The left adnexa was involved in adhesions, the left tube was enlarged, and there was a 3 cm cyst in the left ovary. The abdominal wall cyst was removed, and ovarian cystectomy, left salpingectomy, and contralateral tubal patency test were performed. The ovarian cyst had a dark brown thick liquid inside. Despite",
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"content": " the adhesions, the <|endoftext|>",
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"content": "A 50 year-old male, with a history of coronary arterial bypass grafting 14 years back, presented with shortness of breath and dry cough. An X-ray revealed a large mass in the left hemithorax adjacent to the heart silhouette. A chest CT demonstrated the presence of a mass with smooth edges, in middle mediastinum next to the heart and partially intrapericardial (Fig. ). The mass was of heterogeneous density and of",
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"content": " 11 cm size. Presence of <|endoftext|>",
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"content": "A 71-year-old female with a past medical history of bronchiectasis was investigated by respiratory physicians for a lobulated opacity seen at the right lung base on computed tomographic (CT) scan of the thorax. A repeat CT scan, 2 months later, which included the upper abdomen, showed that the lung opacity had virtually resolved. However, several lymph nodes lying along the mesenteric vessels had now become more prominent, the largest measuring 1.7 cm in short axis. These nodes had necrotic low-density centres and peripheral enhancement. Due",
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"content": " to concerns that the patient may have lymphoma or intraabdominal malignancy (the patient also reported coincidental weight loss), a CT abdomen and pelvis was performed. This demonstrated a left ovarian mass with intraabdominal lymph nodes consistent with a potential diagnosis of ovarian cancer with lymphatic and omental metastases. There were no radiological or haematological features of hyposplenism.\nA pelvic ultrasound scan (USS) confirmed a cystic mass with a solid component lying within the left adnexa, measuring 33 × 25 × 59 mm. In light of these findings, total abdominal hysterectomy, bilateral salpingo-oophorectomy, and omentectomy were performed by the gynaecologists. However, pathological examination of the resection specimen was normal.\nSix months later, a follow-up USS showed several large intraabdominal lymph nodes with necrotic centres lying along the midline, the largest measuring 53 mm in diameter. An USS-guided percutaneous biopsy of one of these lesions withdrew 20 mls of thick white material. Two further needle passes only withdrew fragments of material, which were later proven to be skeletal muscle and fibroadipose tissue.\nThe patient was then referred to the General Surgical service for minilaparotomy and biopsy of mesenteric lymph nodes. Her only clinical symptom continued to be weight loss. At operation, multiple, large cystic masses within the root of the small bowel mesentery were noted, the largest measuring approximately 15 cm in diameter. Due to the multiplicity of these <|endoftext|>",
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"content": "A 75-year-old man was referred to our Saitama Medical University from a local hospital, where he had presented with gait disturbance and a computed tomography (CT) scan had demonstrated an extra-axial mass, suspected to be a calcified subdural or epidural hematoma. Three months previously, he had suffered a fall in the bathroom without any head trauma, and also had a history of knee joint inflammation. On admission, the findings of detailed neurological examinations were essentially normal, but the patient was unable to walk because of knee pain. A CT scan demonstrated a right frontal mass that compressed the frontal lobe, and calcifications at the border between the mass and the cortex (\n). There were erosions of the skull overlying the mass, as well as elsewhere on the cranial vault (\n). Myeloma with skull involvement was strongly suspected. Initial laboratory examinations revealed elevated serum levels of immunoglobulin G (4435 mg/dL) and immunoglobulin lambda chain (292.0 mg/L). Urinalysis was positive for Bence Jones protein (BJP). The tumor was well enhanced by gadolinium contrast, and a flow void with linear enhancement suggestive of large vessels with",
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"content": " in <|endoftext|>",
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"content": "The patient is a 29-year-old female with a history of diabetes mellitus type 1 who presented to the clinic for evaluation of recurrent symptoms of sinusitis and a persistent nasopharyngeal mass. Her symptoms first started at the age of 12 with chronic nasal congestion, repetitive sinus infections and chronic cough. Her tonsils and adenoids were removed at the time, but her symptoms persisted. Between the ages of 13 to 15 she was found to have a recurrent adenoid mass and tonsillar regrowth. She underwent another adenoidectomy and tonsillectomy. Microscopic description of the specimen showed overall preservation of the architecture with follicular hyperplasia and mildly expanded paracortex with scattered immunoblasts. The follicles show polarized germinal centers and contain numerous tangible body macrophages. Immunohistochemistry showed that the interfollicular paracortical cells are positive for CD3, CD5, CD10, CD43, BCL-2, CD1a, CD7, CD4, CD8, and TdT. The tumor was also negative for clonally rearranged immunoglobulin heavy chain gene and negative for clonal T-cell receptor gamma chain gene rearrangement. Additionally, the patient was noted to have an enlarged right cervical lymph node. Due to concerns about malignancy she was hospitalized for a bone marrow biopsy that was deemed negative.\nOver the following years the patient developed progressively worsening severe thick nasa",
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"content": " l drainage, rhinorrhea, frontal pressure and headaches, <|endoftext|>",
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"content": "The present case report is about a 64-year-old Caucasian man was transferred to our hospital with the diagnosis of FG complicated by septic shock. His past medical history was significant for hypertension, mild chronic renal insufficiency and diabetes mellitus type 2 controlled with oral hypoglycaemic agents. He was admitted to the intensive care unit due to progressive respiratory deterioration and hemodynamic instability. On examination, the patient presented with a FG involving the scrotum, the perineum, the right ischial area and extended to the lower abdomen. A multi",
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"content": " disciplinary approach involving intensivist, endocrinologist, urologist and reconstructive surgeon was adopted to address his problems. After hemodynamic stabilization and administration of broad-spectrum antibiotic therapy, the first surgical debridement and a temporary diverting colostomy were performed. After 2 days a second radical debridement was done and a suprapubic cystostomy was established []. After the second debridement negative pressure wound therapy (NPWT) was applied to facilitate wound healing by removing exudates constantly, centripetally contracting the wound and assist in nursing.[] Two large polyurethane foams were cut into several pieces and stapled into the wound, making certain not to staple the urethra or testicles. NWPT was applied with a continuous negative pressure of 125 mmHg. After surgical debridement, the patient received daily hyperbaric oxygen therapy (HBOT) at 2.4 atmospheres absolute for 90 min, until the wound showed healthy granulation tissue. The empiric antibiotic treatment was tailored according to blood and wound culture findings. Blood culture results were positive for methicillin-resistant Staphylococcus epidermidis. Wound cultures taken during the operation grew Proteus mirabilis and Enterococcus faecalis. During NPWT there were no signs of deep wound infection. NPWT dressing was changed and reapplied twice a week, until the presence of healthy granulation tissue with no sign of infection was observed []. After 21 days of NPWT the patient was ready for the next stage of reconstruction. Skin and soft-tissue defects of the lower <|endoftext|>",
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"content": "An 80-year-old Japanese woman with no significant comorbidities noticed a bilateral tingling sensation o",
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"content": " n the <|endoftext|>",
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"content": "A 56-year-old female was referred to our department from another facility in the patient’s area for a rapidly progressing tumor in the gallbladder and liver area. The patient reported several-month right upper quadrant pain and 4-kg weight loss over the past year. There was no laboratory sign of obstructive jaundice at the day of admission. Preoperative CT and MR scan (Figs. and ) of the liver was performed, and the patient was diagnosed with a tumor in the gallbladder area with a relatively massive infiltration of the S5 and S6 liver segments and extensive regions of necrosis. Given the potentially resectable lesion according to preoperative imaging, exploratory laparotomy was indicated to attempt radical resection. During the exploration, a voluminous tumor was found attached to the peritoneum. Intraoperative ultrasound was performed and revealed a tumor originating from the gallbladder bed area and reaching up to the area of the hepatic hilum and extensive involvement of the hepatoduodenal ligament by the tumor through the lymph nodes. The tumor was classified as inoperable due to this finding. But during the exploration, however, a rupture of the fragile tumor occurred with ",
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"content": " massive <|endoftext|>",
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"content": "A 63-year-old right hand dominant female sustained a fall injuring her left shoulder. She was initially seen in a local emergency room (ER) on the day of the injury. An anteroposterior radiograph was performed in the ER and the diagnosis of a lateral clavicle fracture was made with sling and swathe as the treatment. Orthopedically, the patient was seen in follow-up two weeks thereafter in clinic. On physical inspection, a bony prominence was noted in the region of the supraspinatus muscle, seemly protruding through the trapezius muscle (Figure\n). The patient was neurovascularly intact with full motor function and normal sensation to light touch over the left upper extremity. Both anteroposterior and the axillary radiographs were obtained. The anteroposterior radiograph (Figure\n) of her shoulder revealed a Type V fracture of the lateral clavicle in what appeared to be in acceptable position, however, the axillary projection showed the distal end of the proximal clavicular segment to be significantly posteriorly displaced (Figure\n).\nThe patient was subsequently taken to the operating room at which time the lateral clavicle, AC joint, and acromial areas were surgically exposed. The proximal clavicular segment was indeed posteriorly displ",
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"content": " aced and buttonholed through the trapezius <|endoftext|>",
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"content": "A four-year-old boy was scheduled for cleft palate repair, as the third patient on the list. After managing two adult patients earlier, the corrugated tubing of the circle breathing system was changed to the pediatric type and tested for leaks. Anesthesia was induced with sevoflurane using JRMATP. After tracheal intubation, the circle breathing system was used with pressure-controlled ventilation (PCV). After a few breaths, FiCO2 increased to 9 mmHg []. Soda lime was only partly discolored. The flow rate setting in the ventilator (i.e., the flow rate used to achieve the set inspiratory pressure, an equivalent of Pramp or ‘rise time’) was i",
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"content": " ncreased and FiCO2 became zero. With manual ventilation, FiCO2 increased whenever the tidal volume was delivered <|endoftext|>",
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"content": "ON ADMISSION This",
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"content": " is a gentleman who is intubated comfortable with minimal sedation . He was afebrile with a temperature of 99.1 . His pulse was in the 70s blood pressure 119 58 . He was breathing 12 per minute and saturating 98 . His CVP is ranging from 07-27 . He was intubated and has a nasogastric tube . His neck has a well-healed right carotid endarterectomy scar . There is also a well-healing tracheostomy scar . The lungs were clear to auscultation bilaterally . The heart was regular with an S1 and S2 . The abdomen was soft nontender nondistended with normoactive bowel sounds . The extremities were without edema . The left arm was in a cast . <|endoftext|>",
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"content": "A 13-year-old boy from Terhathum District presented to the out-patient department of our hospital with complaints of not able to close the right eye, increased lacrimation, mouth deviation, and swelling of the right side of the face for 2 days.\nHe was fine before 2 days when he was slapped and punched over the face during a quarrel with a friend. However, he could not recall a particular site of insult. Following the trauma, he noticed that he was unable to close the right eye completely. There was increased tear production from the right eye. He also noticed deviation of the face to the left side. There was swelling on the right side of the face too. During the first visit, the patient did not reveal a history of trauma; later, only the parents reported the history of trauma.\nThere was no fever, loss of consciousness, limb weakness, cough, and ear discharge. He did not complain of decreased hearing or ear pain in the past. There was no difficulty in swallowing or aspiration. He denied a history of any recent viral infection, namely, mumps, measles, or herpes zoster. He did not have any other comorbidities. A history was taken from his mother and she denied of any known illness in other family members. The patient was not taking any medicines in the recent past and did not have any allergies to drugs or other substances.\nOn examination, he was 41 kg. His vital signs were within the normal range. The patient was sitting comfortably in the chair. The angle of the mouth had deviated to the left side (). There was an absent forehead crease on the right side of the face (). He could not close the mouth completely and therefore could not blow the cheek () and snarl. He was not able to close the right eye completely (). On the otoscope examination, the right tympanic membrane had bulged and ",
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"content": " was erythematous. His <|endoftext|>",
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"content": "We report the case of a 77-year-old female with left elbow pain for five months without any prior trauma who received initial treatment at a local hospital in Southern Thailand. She was diagnosed with septic elbow, and open arthrotomy of the elbow was performed and she was given IV antibiotics. The culture results did not identify any specific causative organism at that time. Her symptoms did not resolve, she had a chronic wound and persistent elbow pain, and she was referred to our institution, the major tertiary care and referral center in Southern Thailand, for further investigations and management.\nShe did not have any underlying diseases. The history regarding past pulmonary infection was negative. She did not take any immunosuppressant or herbal medicine. The physical examination at our institute showed a chronic wound at the lateral aspect of the elbow about 0.5 x 2.0 cm in size with clear yellow fluid discharge. The elbow was swollen and warm. Her elbow range of motion was limited due to pain. Laboratory investigations showed a white blood cell count of 4,190/μL with 63% polymorphonuclear neutrophils (PMN). The renal function tests and electrolytes were all within normal limits. Erythrocyte sedimentation rate and C-reactive protein were elevated at 114 mm/hr and 8.48 mg/L, respectively. Radiographs revealed osteolytic lesions around the elbow joint and severe bone destruction with dislocation of the elbow joint (Figures , ).\nA magnetic resonance imaging (MRI) showed abnormal bone marrow edema involving the distal humerus, proximal radius and ulna with a moderate amount of joint fluid with diffusely enhanced thickened synovium. There was severe destruction of the elbow joint (Figures -), which we diagnosed as septic arthritis and osteomyelitis of the elbow.\nDue to the chronic presentation, negative culture results and severe destruction of the joint, we suspected an atypical infection such as TB. We suggested surgery for the definitive diagnosis and as having the best likely",
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"content": " outcome, and the patient agreed. Chest radiograph was also reviewed and did <|endoftext|>",
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{
"content": "A 32-month-old Middle Eastern boy was born full term at a community hospital in Michigan with birth weight of 3135 g (15.0 percentile). He had normal prenatal ultrasounds. He passed meconium at birth and had no other complications including prolong neonatal jaundice or dehydration. His CF NBS showed serum IRT 139 ng/ml and was negative for the 40 gene mutations panel. At 1 month of age, he developed a wet cough without any other symptoms. He was followed by his primary care provider (PCP), and no treatment was given at the time. His symptoms continued on and off until 1 year of age. At 1 year, the mother noticed increased frequency of productive cough, lack of appetite, and poor weight gain. His weight-for-age percentile ranged from 0.3 to 5.0. His stools were reportedly normal. He had no excessive sweating. He was referred to an outside asthma/allergy specialist for evaluation of asthma. He was prescribed budesonide without any improvement. He had frequent pharyngitis and otitis media that were treated with oral ",
"role": "user"
},
{
"content": " antibiotics that reportedly helped treat acute infection, but the cough persisted. He was also prescribed a H2 blocker for possible gastroesophageal reflux disease, but no improvement in symptoms was noted. Family history was negative for CF.\nAt 30 months of age, he was seen by his PCP for one week of cough and fever. He was treated with amoxicillin. His symptoms continued to worsen despite oral antibiotics, and he had two episodes of small-volume hemoptysis. He was subsequently admitted for community-acquired pneumonia and influenza B. Chest X-ray showed diffuse ill-defined opacities in the perihilar area and diffuse bronchiectasis. During the hospitalization, pediatric pulmonary consult was obtained. Given the negative NBS, it was stated that CF was unlikely and no sweat chloride test was recommended. He had a normal videofluoroscopic swallow study. Immunodeficiency workup revealed elevated immunoglobulin levels, protective vaccine titers <|endoftext|>",
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[
{
"content": "A 71 year old lady with a 6-year history of seropositive rheumatoid arthritis presented to her general practitioner with bilateral swelling and pain in the forearm.\nShe had been on methotrexate, which was stopped a few weeks prior to presentation because of breathlessness secondary to rheumatoid and methotrexate-induced pneumonitis. She was put on a short course of high-dose prednisolone, 30 mg/day, for her pneumonitis. Other medications included etodolac 600 mg daily, paracetamol for analgesia and lansoprazole 15 mg daily.\nShe developed swelling in the right forearm a few w",
"role": "user"
},
{
"content": " eeks after being on prednisolone, followed by similar swelling in the left forearm a couple of weeks later. When <|endoftext|>",
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[
{
"content": "During routine upper limb dissection for first year medical students, the BP of 43-year-old female cadaver showed the complete absence of MCN and variant branches of MN in the arm of both the upper limbs.\nIn the right axilla, the lateral cord of BP had three branches i.e. lateral pectoral nerve, nerve to CB and lateral root of MN. The lateral pectoral nerve pierced the clavipectoral fascia and supplied the pectoralis major as usual but during its course it communicated with the medial pectoral nerve (MPN) of medial cord of BP (). The MCN was completely absent. The nerve to the CB was a small motor twig arising directly from the lateral cord which innervated the CB muscle. The lateral and medial root of MN formed the MN proper and descended between the biceps brachii and brachialis muscle. It then crossed the brachial artery",
"role": "user"
},
{
"content": " from lateral to medial and finally entered the cubital <|endoftext|>",
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[
{
"content": "A 22-year-old Caucasian man with a medical history of epilepsy, nephrolithiasis, and nutcracker syndrome presented with abdominal and perineal pain. The patient’s family history was negative for nutcracker syndrome and pelvic congestion syndrome. The pain was ongoing for approximately 3 years before the initial consultation, and a left renal vein transposition was undertaken 1 year before initial consultation, without any improvement in his symptoms (Fig. ). The pain was located in the left flank as well as variably in the left lower quadrant and left lower back. The pain consistently radiated to the groin and perineum and variably radiated to the left posterior thigh. The patient described the pain as sharp, shooting, and piercing. His pain was constant, with a baseline intensity of 6/10 on the visual analogue scale. His pain improved with medications, including gabapentin and hydrocodone-acetaminophen, restricting movement, and lying flat; it worsened with movement and sitting upright or standing. Associated signs included a varicocele, which had been repaired 6 years before initial consultation, and associated symptoms included infrequent nausea and vomiting. The patient’s vital signs were within normal limits. His physical examination revealed tenderness to palpation over the left flank without rebound tenderness or guarding. His laboratory test values were normal, except for microscopic hematuria on urinalysis. Due to continued flank pain at 6 months postoperatively, a repeat renal angiogram/venogram was obtained, which showed that although the left renal vein was successfully transposed, the",
"role": "user"
},
{
"content": " left renal vein remained compressed <|endoftext|>",
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[
{
"content": "A 15-year-old obese boy visited our clinic with a painful hip on the left side. The complaints arose one year earlier after he had fallen on his hip. At that time a mild epiphysiolysis was diagnosed on presentation in the emergency room. He was admitted with bed rest and three days later an in situ fixation was performed with one cannulated screw (Figure ). The postoperative recovery was without complications and he was pain free after a few weeks. As it was thought that the fracture had consolidated, the screw was removed 11 weeks after initial placement. After this procedure had been performed his hip became increasingly painful and he experienced reduced mobility. Ten weeks after the screw removal, he fell again, complaining once again of severe pain in his hip. Plain radiographs were performed and a progressive abnormal position of the head of the hip with callus formation was seen. Initially the conservative treatment consisted of physiotherapy. Because of the persistence of disability he was referred to our orthopedic children’s clinic several months later.\nAt that time he had a painful gait with a severely limited left hip function with 70 degrees of flexion. His left leg was externally rotated, with an internal and external rotation in extension of 0–30–50 degrees. The X-rays depicted a severe SCFE with a slip of 70 degrees and an open growth plate (Figure ). Given the seriousness of the slip and the open growth plate, a re-(screw) fixation of the epiphysis was performed with an additional subtrochan",
"role": "user"
},
{
"content": " teric correction osteotomy (according to Southwick). The postoperative course was uncomplicated (Figure ). After an initial period of six weeks of unloaded mobilization, weight bearing was supervised by the physiotherapist. During the last outpatient appointment, two years postoperatively, he was still found to be limping slightly, but he was pain free. On examination there was a leg length difference of 2cm with a hip motion of 100 degrees of flexion and an internal and external <|endoftext|>",
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[
{
"content": "A 40-year-old obese male presented to our Level 1 Trauma Center following multiple gunshot wounds (GSWs) to the left upper and lower extremities. The patient was hemodynamically stable and presented with a Glasgow Coma Scale of 15. On exam, there were 4 GSWs with 2 in the left forearm and 2 in the upper left thigh. The patient had decreased range of motion and paresthesia of the left lower extremity but adequate capillary refill in all extremities. There were palpable pulses of the left femoral, popliteal, dorsalis pedis, and posterior tibial arteries. Initial emergency department imaging demonstrated no fractures in the left upper and lower extremities but shrapnel was appreciated. A CT angiogram of the abdomen with runoff demonstrated a left traumatic arteriovenous fistula involving the left deep femoral artery and left common femoral vein w",
"role": "user"
},
{
"content": " ith adjacent bullet fragment (, , ). There was also shrapnel in the soft tissues anterior to the pubic symphysis <|endoftext|>",
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[
{
"content": "An 83-year-old male patient had osteoarthritis for 7 years in the right knee, with no flexion contracture or highly varus and valgus deformity. Because of extreme pain, the patient underwent magnetic resonance imaging, which showed lesions in the medial femoral condyle cartilage in the weight-bearing region; the same findings were confirmed during the TKA operation (). He had previously",
"role": "user"
},
{
"content": " undergone left primary TKA for incapacitating knee pain recalcitrant to conservative <|endoftext|>",
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]
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[
{
"content": "A 56-year-old male welder presented to a hospital with sudden onset of",
"role": "user"
},
{
"content": " left foot drop. He underwent lumbar magnetic resonance imaging (MRI) and mild disc protrusions of L3-4 and L4-5 were observed (Fig. ). The initial diagnosis was L5 radiculopathy with profound ankle dorsiflexor weakness. Spine operation was planned and electrodiagnosis (EDX) was conducted to determine the exact location of lesion and to differentiate peripheral nerve lesions before surgery in another clinic (Table ).\nThe patient had been experiencing foot drop for 9 days and initial EDX results revealed abnormal spontaneous activity (ASA) in the left tibialis anterior (TA), peroneus longus (PL), and extensor hallucis longus (EHL). These findings suggested that the patient's foot drop was more likely due to peroneal nerve injury than lumbar radiculopathy. ASA, such as fibrillation, usually appears within 5 to 6 weeks after the onset of the lesion in radiculopathy.[ Consequently, the surgery was cancelled.\nThe next day, the patient was referred to our outpatient clinic for peroneal neuropathy. He complained of numbness in the area below the knee and especially in the dorsal aspect of his foot. These symptoms began 10 days prior and he did not recall any history of trauma. On physical examination, muscle manual testing (MMT) of the TA and EHL revealed a trace grade, while the peroneus muscle showed poor plus grade. There were no signs of TA or peroneal muscle atrophy. Soft tissue swelling was not palpable around the fibular head and popliteal fossa. The palpation of the lateral aspect of the knee showed no degree of tenderness. The Tinel sign over the fibular head was negative. The patient's ankle and knee jerks were normal.\nEDX, performed on the day of the patient's visit to our outpatient clinic, showed common peroneal neuropathy around the left knee with significant axonal denervation in the TA and PL. Compared with the contralateral limb <|endoftext|>",
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[
{
"content": "A 54 year old female Caucasian patient presented to the orthopaedic outpatient clinic complaining of left arm and left knee pain. She had been diagnosed with malignant mel",
"role": "user"
},
{
"content": " anoma of the palpebral and forniceal conjunctiva 2.5 years before and had received treatment at the regional ocular oncology centre in the form of surgical excision, cryotherapy and adjuvant Mitomycin C.\nDuring her oncological follow up 30 months following the original diagnosis, multiple bilateral pulmonary metastases all measuring <0.5 cms in diameter as well as a 4 × 2 cm right ischial lesion were identified. She was complaining of left arm and left knee pain and was therefore referred to the orthopaedic clinic.\nThe pattern of the pain was constant with occasional nocturnal exacerbations and was aggravated by weight bearing activities of both extremities. Clinical examination demonstrated localized areas of tenderness over the midshaft area of the left humerus as well as over the anteromedial aspect of the left proximal tibia. Furthermore a non-fluctuant swelling measuring 2 × 2 centimeters in diameter was palpable over the corresponding left proximal tibial metaphysis. All neighbouring joints examined normal. Her right ischial lesion was asymptomatic.\nRadiographic evaluation demonstrated lytic lesions of the left humeral diaphysis and proximal tibial metaphysis with associated cortical involvement and ill defined zones of transition, however no evidence of fracture (Figure ). A bone scan confirmed the presence of three active areas corresponding to the lucent radiographic areas of the left humerus, left tibia and right ischium. It did not identify any further skeletal lesions\nRegarding her osseous lesions she underwent intramedullary nailing procedures of both long bones on a semi-elective basis due to the danger of impending fracture. According to the Mirels classification for metastatic bone disease at risk of fracture, [] she scored 9 points for the humerus and 10 for the tibia.\nA standard reamed and locked nailing technique was applied for stabilization of both bones with no associated intra-operative complications (Figure <|endoftext|>",
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[
{
"content": "A seven and half year-old boy visited the ",
"role": "user"
},
{
"content": " outpatient clinic of Pediatric Dentistry Department, Faculty of Dentistry, Cairo University in June 2015 with a chief complaint of pain on the lower right molar area. The patient’s mother stated that the pain was at times throbbing in nature, and child is not able to chew on this side.\nClinical examination showed a badly decayed, lower second primary molar with related localized intraoral abscess, where the lower first primary molar was intact. The patient had poor oral hygiene; he had not received any professional dental care, and was very apprehensive.\nRadiographic examination revealed root resorption and bone rarefaction related to lower second primary molar. The interesting finding was a considerable amount of root resorption of the distal root of the adjacent lower first primary molar (\n).\nThe case was managed by performing pulpectomy\nto the lower second primary molar, with root canals filled with calcium hydroxide paste with iodoform (Metapex, Meta Biomed, Republic of Korea). The tooth was then restored with high viscosity glass ionomer (GC Fuji IX GP capsule, GC corporation, Tokyo, Japan) (\n). The lower first primary molar was not touched and instead monitored. No antibiotics or analgesics was prescribed.\nUnfortunately, the patient’s mother did not want follow-up appointments in person, however, she was contacted on the phone, after 2 weeks, 3 months and 6 months, and she said everything was fine and there was no swelling or pain.\nAt about 8 months from the treatment appointment, the patient’s mother visited the outpatient clinic with the patient for other reasons, and decided to pass by the Pediatric Dentistry Department for patient follow-up. Clinical examination showed no signs or symptoms, occlusal restoration was intact, and radiographic examination revealed arrested root resorption, on both molars, and an increase in the density of bone although this was not at a <|endoftext|>",
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[
{
"content": "A 41-year-old married female applied to our clinic with a left inguinal mass. The patient had been primary amenorrheic, but had not consulted a doctor. Clinical examination showed a bulging mass of 15 cm × 10 cm on the lateral side of the left inguinal canal and another 3 cm × 4 cm mass in the right inguinal region []. The vulva and perineum were normal in appearance, the vagina was 6 cm long but ended blind, pubic and axillary hair was sparse; however, the patient had normal breast development as well as a normal female phenotype. The abdominal ultrasonography (USG) and magnetic resonance imaging revealed the absence of the uterus and ovaries. They also showed a 13.7 cm × 8 cm × 12.4 cm polypoid cystic mass with a regular surface in the left inguinal region extending from the hip joint to the level of labia majus, and a solid 3.2 cm × 2.8 cm mass in the right inguinal region. In hormonal analysis, follicle stimulating hormone was found to be 9.68 mIU/mL, luteinizing hormone was 15.74 mIU/mL, estradiol was 56.07 pg/mL, and testosterone was 1.83 ng/mL. The tumor markers including carcinoembryonic antigen, CA125, alpha-fetoprotein, lactate dehydrogenase, and alkaline phosphatase were within normal ranges. The chromosome test revealed a 46, XY karyotype. The diagnosis of CAIS was made based on these findings.\nAfter the diagnosis, we performed an exploratory laparotomy. Internal female organs were absent. The right testis was of normal size, and the left one was swollen with a cyst. A gonadal tumor in the left inguinal region measuring 13 cm × 8 cm × 12 cm and a 3 cm × 4 cm one in the right inguinal region were extirpa",
"role": "user"
},
{
"content": " ted. Vaginoplasty was not performed as the vagina was 6 cm long, and this was thought to be adequate for sexual intercourse.\nHistopathologic examination revealed immature <|endoftext|>",
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[
{
"content": "A 46-year-old male was referred to the Department of Oral and Maxillofacial Surgery, Aarhus University Hospital, Denmark, with a 3-week history of infection after tooth extraction in the left side of the mandible. He was diagnosed with gout in 2004, and was on regular medication with allopurinol, prednisolone and alendronate for the last 14 months. He was a non-smoker with moderate use of alcohol (two to three units daily).\nThe patient presented with a large swelling in the left side of the face with pus from the extraction sockets of the lower left first and second molars. Despite medical advice he refused admission for treatment with intravenous antibiotics and drainage, but accepted a prescription for oral antibiotics (penicillin one MIU four times daily and metronidazol 500 mg three times daily) to use at home. One month later, he went to his general dentist with persistent infection and worsening of the swelling. The infection had escalated dramatically and he was immediately admitted to the ",
"role": "user"
},
{
"content": " hospital <|endoftext|>",
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[
{
"content": "We present a case of a nine-year-old, previously healthy boy, presenting to the emergency department of a te",
"role": "user"
},
{
"content": " rtiary care hospital with complaints of severe frontal headache for the last two weeks but <|endoftext|>",
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]
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[
{
"content": "A 63-year-old male presented to the emergency department of our institution in January of 2011 with an open pilon fracture of his left tibia along with a fracture of the distal fibula (). His medical history was significant for diabetes mellitus being treated with insulin therapy. The patient's fracture was immediately treated in the operating room with an open reduction and internal fixation with plates and screws. Postoperatively ( and ), the patient received intravenous antibiotic therapy with ceftriaxone, amikacin, and metronidazole for 3 days and the patient was discharged fro",
"role": "user"
},
{
"content": " m the hospital 1 week after the initial operation. One month after the operation, <|endoftext|>",
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[
{
"content": "The patient was a 75-year-old woman, who had developed left shoulder pain five years earlier without any known precipitating factor. She presented to our department because of gradual difficulty in ",
"role": "user"
},
{
"content": " raising her left arm and worsening pain. Physical examination on presentation did not reveal any swelling or feeling of heat in the left shoulder. The range of motion of the left shoulder showed extremely severe restriction; namely, flexion 80°, abduction 60°, and external rotation 0°, and prominent impingement symptoms were found. On plain radiographs and computed tomography (CT), prominent shoulder arthropathic changes and numerous calcified lesions around the joint were found. On plain magnetic resonance imaging (MRI), around the shoulder an irregular hypointense region was identified in the center on T1-enhanced images and on T2-enhanced images (). Routine blood examinations did not reveal any obvious abnormalities. This patient was diagnosed with synovial osteochondromatosis associated with a massive tear of the rotator cuff and shoulder arthropathic changes, for which the treatment RSA was chosen.\nIntraoperative findings: A delto-pectoral approach was used. Full-thickness tears of the supraspinatus and infraspinatus tendons were found. When the joint capsule was incised, synovial proliferation and a whitish mass-like lesion, seemingly adherent to the synovium, were found. The intraarticular mass was resected to the extent possible, but the cartilage in the humeral head was severely damaged, while that in the glenoid cavity had almost disappeared. After loose body resection, RSA was performed.\nThe postoperative course was uneventful, with the left shoulder pain disappearing from early in the postoperative period. At one year postoperatively, there was no recurrence of pain and the left shoulder range of motion showed improvement to flexion 140°, abduction 130°, and external rotation 30°. Moreover, no complications such as recurrence of osteochondromatosis, implant loosening, or infection were seen.\nThe loose body was found to consist of a cartilage component and bone tissue with hyalinization (). No findings <|endoftext|>",
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[
{
"content": "We report the case of a 52-year-old female who was referred to the surgical hepatobiliary team for assessment of a focal liver lesion found on a routine follow-up CT.\nIn 1975 (aged 15) the patient was diagnosed with an adenoid cystic carcinoma of the left submandibular gland. The primary lesion was excised followed by adjuvant chemotherapy and radiotherapy. Initial follow-up was for 10 years before discharge. In 2008 she represented with a lump at the left angle of mandible. A fine needle aspiration was suggestive of either benign pleomorphic salivary adenoma or recurrent ACC. A multidisciplinary team decision was made to treat the lesion conservatively. In 2010 the lesion had increased in size and a left total parotidectomy was attempted. Unfortunately, previous surgery and radiotherapy meant that only the superficial gland could be removed safely. Histological examination confirmed recurrence of salivary gland ACC.\nA routine follow-up CT in February 2013 demonstrated a focal liver lesion that was suspicious of metastasis. No other metastases were found on further CT scans of the brain, head, neck, and chest. An MRI of the liver confirmed the presence of a solitary lesion (see ). A biopsy of the lesion confirmed the histological appearance of a metastatic adenoid cystic carcinoma that was of identical morphology to the parotid tumour excised in 2010. This had been performed prior to the patient being referred to our unit.\nThe patient was otherwise medically fit and did not have any other significant medical history. She did not take any regular medications.\nIn June 2013 the patient underwent a nonanatomical segment V liver resection and cholecystectomy. The resected tumour measured 25 × 15 × 25 mm and demonstrated a 7 mm hepatic resection margin. The tumour was completely excised. No perineural, lymphatic, or vascular invasion was identified (). The patient made an uncomplicated postoperative recovery and was discharged home.\nA 6-month follow-up CT of the neck/chest/abdomen and pelvis was performed as part of her follow-up. This did not demon",
"role": "user"
},
{
"content": " strate disease recurrence <|endoftext|>",
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[
{
"content": "A 56-year-old man was referred to the gastrointestinal department with complaints of 2-weeks history of melena and epigastric dull pain. No mucous stool, no bowel habits change was present and he denied fever, nausea, or vomiting. Meanwhile, the patient's medical and family histories were normal. Physical examination revealed there was no anemia or enlarged lymph nodes such as Virchow lymph nodes. For laboratory tests, occult blood test of stool was positive. Hematological test revealed a normal level of hemoglobin (Hb), 130 g/L",
"role": "user"
},
{
"content": " . Peripheral blood tumor markers were within the normal range <|endoftext|>",
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[
{
"content": "A 51-year-old woman present",
"role": "user"
},
{
"content": " ed with a massive painless lump on both of her thighs that had been enlarging for the past 6 months. The patient denied any history of trauma, manipulation, or injection around the lump before. She was otherwise healthy despite her lumps. However, she had a history of lymph node tuberculosis on her neck about 25 years before and underwent tuberculosis chemotherapy regiment for about six months.\nOn the local physical examination, we found a painless non-mobile distention on her gluteal and upper femoral region bilaterally with some fluctuation and cystic consistency on palpation of the mass. The initial largest diameter of her thigh was 60 cm on the left and 45 cm on the right. There was no signs of inflammation, sinus or fistula around her thighs and buttock, or any remarkable signs on physical examinations (). Laboratory examinations however, showed elevated level of ESR and CRP. Mantoux test were inconclusive due to previous infection of tuberculosis. Radiological examination showed no signs of abnormality besides the expanding soft tissue shadow especially on her left femur region.\nMRI examinations were then performed over the lumbosacral and pelvis region. Sagittal T2 weighted MR images of the sacrum showed destruction on anterior lower sacral segments, with hyperintense anterior lesion and presacral abscess. Axial T2 weighted images confirmed sacral body destruction and extension of the hyperintense lesion that involved the insertion of piriformis muscle (a and b).\nPelvic axial fat-suppressed (FS) T2 weighted images gave another extended view of the lesion, showing lateral extension of the lesion over the posterior ilium that also extended to superior and inferior filling the gluteal compartment beneath the gluteus maximus and tensor fascia lata (c). Involvement of the piriformis muscle and gluteus medius were confirmed at the coronal FS-T2 images of proximal femur, in which there was a hyperintese bony lesion at the tip of greater trochanter. <|endoftext|>",
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[
{
"content": "A 66-year-old female presented with a history of SCLC of right middle lung lobe (stage 1). She has undergone right middle lobe (RML) lobectomy followed by four cycles of adjuvant carboplatin and etoposide. Fou",
"role": "user"
},
{
"content": " rteen month later, she developed recurrence in her subcarinal/paratracheal nodes confirmed on endobronchial ultrasound (EBUS) biopsy. She then had concurrent chemotherapy with radiation completed followed by prophylactic cranial irradiation. Again she developed recurrent disease in celiac axis nodes confirmed on biopsy for which she was started on nivolumab. Ten months after starting nivolumab therapy, the patient presented to the office complaining of dizziness, imbalance, and double vision. Past medical history included chronic obstructive pulmonary disease (COPD), diabetes mellitus type 2, neuropathy, and myocardial infarction (MI). She was a former smoker with 75 PPD smoking history and had a family history significant of lung cancer.\nPhysical examination was positive for a significant vertical nystagmus. MRI of the brain in November, 2018 showed extensive symmetric linear hyperintensity in T2 Flair throughout medulla, dorsal pons, and midbrain with post contrast enhancement (Figure ).\nThe patient was started on oral steroids with a tapering dose. Nivolumab was held for six weeks and her symptoms improved over this period. Then she was given a re-challenge dose of nivolumab but her vision and balance worsened again. Again, she was started on oral steroids with a tapering dose and nivolumab was held. Blurry vision and imbalance were improved within a few days, but nystagmus gradually improved over five months. The patient remained off treatment with observation alone for nine months when MRI of the brain showed resolution of abnormal linear enhancement of the brain parenchyma (Figure ), however, follow up CT demonstrated focal area of consolidation in superior lobe of right lung and enlarged posterior pancreatic lymph node.\nThe positron emission tomography (PET) scan showed mild activity nodule in right upper lobe (RUL), <|endoftext|>",
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[
{
"content": "A 62-year-old man was admitted to our hospital with complaints of dyspnea and chest pain of 1 year’s duration. His electrocardiogram (ECG) showed the normal sinus rhythm with T-wave abnormalities, echocardiography indicated an ejection fraction of 55% and a normal valve function, and coronary angiography revealed 4-vessel disease. Consequently, coronary artery surgery was decided.\nThe patient underwent 4-vessel coronary bypass surgery. After sternotomy, cardiopulmonary bypass was instituted by using ascending aortic cannulation and 2-stage venous cannulation in the right atrium. Thereafter, the aortic cross-clamp was remov",
"role": "user"
},
{
"content": " ed and the proximal anastomosis was performed with partial clamping. There were no intraoperative complications. At the <|endoftext|>",
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[
{
"content": "An 18-month-old male child with right microphthalmia and complete corneal opacity, midline cleft palate and a repaired cleft lip presented to us with a cystic swelling protruding into his oral cavity. The child had undergone repair of his cleft lip at 10 months of age. Examination of the oral cavity demonstrated a wide complete cleft palate that allowed direct visualization of a completely compressible cystic swelling showing cough impulse.\nComputed tomography (CT) head showed a defect in the floor of sella and sphenoid sinus through which the floor of third ventricle was herniating li",
"role": "user"
},
{
"content": " ke a cerebrospinal fluid (CSF)-filled sac [Figure <|endoftext|>",
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[
{
"content": "A 56-year-old Caucasian man presented to the hospital with a three-day history of a red, painful rash to the first and second digits on the right foot, suggestive of ischemia. The patient stated that three days prior to the development of the rash, he was experiencing numbness and tingling at the site of the eventual lesion. An abdominal aortogram with lower extremity runoff showed patent bilateral renal arteries, patent bilateral common and external iliac arteries, patent right profunda, and three vessel runoff with an intact pedal arch flow. The physical exam was notable for right foot first and second digit duskiness with extreme pain to palpation, along with left foot and leg erythema (Figure ). Bilateral dorsalis and posterior tibial arteries were palpable. He denied any B symptoms and did not demonstrate any lymphadenopathy on an exam. The rest of the patient’s physical exam was normal. His vital signs were also within the normal range. The patient’s history was notable for CLL diagnosed in 2011 through routine lab work showing leukocytosis, with subsequent confirmation via a bone marrow biopsy. He also had a history of untreated HCV thought to be contracted through his extensive intravenous drug use in the 1990s. He was treated for the HCV in 2012 with ribavirin and beta interferon and was cleared of the virus. As the CLL was asymptomatic and not appearing to progress, no treatment for this was commenced and he was under watchful monitoring by his outpatient oncologist.\nAs vasculitis was suspected on initial rheumatologic evaluation, the patient was started on prednisone 60 mg daily as workup commenced. A biopsy of the right foot ischemic lesion revealed ischemic necrosis of the epidermis and dermis, with vascular congestion but no evidence of vas",
"role": "user"
},
{
"content": " culitis and negative direct immunofluorescence. Labs were obtained on admission and during his hospitalization (Tables -). A computerized tomography (CT) scan of his chest, abdomen, and pelvis was negative for malignancy. A transesophageal echocardiogram did not reveal any thrombus. A bone <|endoftext|>",
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[
{
"content": "A 10-year-old boy reported to the Department of Pediatric Dentistry, with a chief complaint of mobile teeth in maxillary and mandibular posterior region and wanted to get them extracted. The medical history of the patient was noncontributory and no abnormality was detected on extra-oral examination. Intraoral examination revealed preshedding mobility in relation to all the present primary teeth, which included the maxillary second molar in the first quadrant, mandibular second molar in the third quadrant and mandibular first and second molar in the fourth quadrant. All the other teeth present in the oral cavity were normal.\nDuring the examination, it was found that maxillary second premolars were not present in the oral cavity and hence a radiograph was done to confirm the clinical findings. An orthopantomogram (OPG) was advised as it would cover the entire dentition and make visible any tooth abnormalities and also help us determine the eruptive status of other permanent teeth. The OPG revealed two very interesting findings, first as suspected the maxillary second premolars were missing along with the absence of right mandibular second molar. Second the right primary mandibul",
"role": "user"
},
{
"content": " ar first molar was single rooted which is an extreme rarity []. <|endoftext|>",
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[
{
"content": "A 56-year-old male without any previous medical history presented to our emergency room (ER) with multiple traumas from a 10 meter fall in a construction field. Physical examination revealed a male patient with a body mass index in the normal range and an acutely ill looking appearance. His right lower leg and ankle were swollen and bruised, and he had a 2 cm laceration wound on the plantar aspect of his right foot. The patient's right ankle had limited range of motion due to pain. The patient had tenderness at the right anterolateral aspect of the mid lower leg and anterior aspect of the ankle. There was grade 1 anterolateral instability of the left ankle. The neurologic examination was normal. Based on the patient's clinical history and physical examination, the orthopedic surgeon suspected a fracture of the right fibular diaphysis and l",
"role": "user"
},
{
"content": " igament injury of the right anterolateral ankle.\nInitial radiographs of the ankle in the anteroposterior and lateral views showed fractures at the diaphysis at the fibula and anterior lip of the tibial plafond (Fig. ). The patient was not able to undergo ankle Mortise view because of his limited range of motion due to extreme pain. In a subsequent lower extremity computed tomography (CT), the orthopedic surgeon in the ER noticed a segmental fracture of the right fibular shaft and the anterior lip of the tibial plafond.\nTo evaluate the ankle ligaments, a turbo spin-echo (TSE) two-point mDixon technique applied to an ankle MRI (Table ) was performed after procuring written informed consent. In addition to the fractures of the right fibular shaft and tibial plafond, this MRI demonstrated a tiny chip fracture of the lateral talar dome. A tiny wafer-shaped talar dome chip fracture fragment about 7 (anterior–posterior diameter) × 3 (head to toe diameter) mm was clearly delineated only in the sagittal T2-weighted mDixon opposed-phase MRI (Fig. <|endoftext|>",
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{
"content": "A 10-year-old girl applied with a complaint of pain in her left foot. She had a history of outward sprain in her left foot about one and a half years ago. She had foot pain increasing with walking since a year and she was limping since two months. No rash, swelling or temperature increase was detected at the ankle or foot joints during physical examination. Pes planus and calcaneovalgus were apparent at the left foot. Jack’s test of toe rising performed by passive pollex extension showed no arch flattening. Talotibial joint movements were free and with minimal pain. She was able to full range of motion for dorsiflexion. Subtalar joint passive supination was limited in the last part. No active supination could be performed in the left foot. Stiffness or shortening were not detected for the calf muscle. Left foot pronation was observed in the walk analysis performed. Plantar flexion could not be performed when patient’s forefoot was in outward rotation. Too many toe sign and hind foot valgus were observed in the standing rear examination (). Besides of non-inflammatory characterized joint pain, juvenile rheumatoid arthritis and such inflammatory conditions were ruled out with detailed blood samples (complete blood count, erythrocyte sedimentation rate, C-reactive protein and rheumatoid factor were normal).\nHer joint hypermobility was assessed with Marshall Test and scored grade 3.\nClinical findings of the patient were considered to conform to PTTD and ultrasound and magnetic resonance (MR) imaging were carried out. However, no pathology was observed in both assessments and MR imaging was repeated as fat suppressed sequenced included and fatty degeneration in tibialis posterior tendon and a decrease in tendon diameter as against the healthy side were observed ( and ). The patient diagnosed with PTTD did not approve surgic",
"role": "user"
},
{
"content": " al therapy, thus she was treated and followed up conservatively. Alternating toe <|endoftext|>",
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[
{
"content": "A 72-year-old male with non-insulin-dependent diabetes mellitus, hy",
"role": "user"
},
{
"content": " perlipidemia, <|endoftext|>",
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{
"content": "A 29-year-old woman who had been bit by an insect on the left calf was admitted to our hospital with a chief complaint of continuous painful swelling of the bit area for 3 days. After scratched, the bite area became red and inflamed. The injury was not considered severe by the patient initially and the swelling of the calf was treated by self-medication with heat-clearing and detoxifying effects. The aggravating swelling and pain of the left calf impelled her to seek medical advice. After admission to our hospital, the patient developed septic shock symptoms characterized with diminished consciousness, pale skin, hypothermia, lack of urine output, and undetectable blood pressure. Laboratory studies revealed a white blood count of 13.8 × 109 cells/L, neutrophil count of 12.24 × 109 cells/L, and 88.7% polymorphonuclear neutrophils. She was admitted to the intensive care unit, receiving intravenous",
"role": "user"
},
{
"content": " fluids and broad spectrum antibiotics treatments. Besides, she denied any history of diabetes mellitus, alcoholism, liver diseases, or trauma.\nIn the intensive care unit, the swelling increased and extended proximally to left knee and foot, complicated with blisters (Fig. A). Additionally, the patient developed cutaneous necrosis in the left ankle and popliteal space. Clinical examination showed her entire left calf was tensely swollen both medially and laterally, and the most obvious pain was localized to the bit area of the left calf. She had a loss of superficial touch sensation and 2-point discrimination over the entire sole of the left calf. She was unable to move her left leg actively, and any passive movements of the left calf, knee, and ankle joints caused severe pain. Palpation of the whole left leg revealed a mildly increased skin temperature and exquisite pain compared with her contralateral leg. The main differential diagnose was from deep vein thrombosis (DVT). Subsequent venous Doppler ultrasonography found no evidence of DVT, and only subcutaneous edema at the lower leg. On the basis of the postmedical <|endoftext|>",
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{
"content": "A 63-year-old Chinese woman presented to our department after the discovery of a mass in the hepatic portal entrance on a CT scan at a local hospital.\nThe patient initially visited the local hospital with complaints of ch",
"role": "user"
},
{
"content": " ronic intermittent abdominal discomfort. A CT scan of the gallbladder, <|endoftext|>",
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]
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[
{
"content": "A 48-year-old male has been suffering from prominent right eye, right conjunctiva congestion, swelling and abnormal intracranial noise for 40 days after trauma. The digital subtraction angiography (DSA) revealed the presence of right carotid cavernous fistula (CCF) (). After the temporary occlusion of the right ICA by compression, the anterior communicating artery was not immediately visualized (), and the posterior communicating artery was also not visu",
"role": "user"
},
{
"content": " alized during the vertebral artery angiography (). In addition, the patient could <|endoftext|>",
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]
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{
"content": "A 93-year-old female patient sought treatment in the emergency room of the University Hospital of the University of São Paulo, presenting with acute upper gastrointestinal bleeding. She had a clinical history of hypertension and cardiomyopathy with chronic atrial fibrillation. She reported dyspnea on mild exertion, together with chronic leg edema. She had been under treatment with carvedilol, captopril, furosemide, and spironolactone for the last 2 years. She complained of epigastric and substernal pain followed by evacuation resembling melena for the last few days before admission. Her first upper gastrointestinal bleeding episode was characterized by the emission of a small amount of blood mixed with saliva from her mouth while sleeping, as noted by her family. Because the bleeding was minimal, she was taken to a primary care facility, where she remained under clinical observation after being started on vitamin K, omeprazole, and intravenous saline infusion. On the next day, she began to bleed again and was referred to our hospital for endoscopic examination. At admission, she was conscious and lucid, although emaciated and pale. There were traces of blood in the oral cavity. Her blood pressure was 95/69 mmHg, and her pulse was 100 bpm. Pulmonary examination revealed decreased breath sounds at the right lung base. The abdomen was slightly painful on gentle palpation of the epigastrium. Rectal examination failed to reveal melena. The laboratory test results are shown in .\nUpper gastrointestinal endoscopy revealed pulsa",
"role": "user"
},
{
"content": " tile extrinsic compression of the esophagus at 25 cm from the superior dental arch (). At the most prominent <|endoftext|>",
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]
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[
{
"content": "A 48-year old woman was being treated for a malignant neoplasm of her left breast. The tumor was a moderately differentiated invasive ductal carcinoma (clinically T1 N0) that was discovered on physical exami",
"role": "user"
},
{
"content": " nation <|endoftext|>",
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[
{
"content": "In 2016, a 30",
"role": "user"
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{
"content": " -year-old woman with a 3rd relapse of the left orbital HPC <|endoftext|>",
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}
]
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[
{
"content": "A 70-year-old woman was referred to our hospital because of right knee dislocation after TKA was performed on her right knee due to severe varus deformity and flexion contracture (figure ). Before TKA, the patient had a 45° flexion contracture and severe varus deformity, according to the patient's records. The patient's knee had dislocated when she first tried to stand and walk on the second day after surgery. The day after the dislocation, the patient was referred to our institute (figure ). We attempted closed reduction of the dislocated knee in the operating room, but this was unsuccessful. In the first operation, size 5 femoral and size 4 tibial components (Genesis II, Smith & Nephew) of a non-posterior-stabilized prosthesis with a size 11 liner were inserted. Paramedian arthrotomy was performed via the previous longitudinal incision, and the knee was exposed. Eversion and lateral dislocation of the patella were attempted; however, the surrounding soft tissues were very tight and further proximal dissection and patellofemoral ligament resection was required to enable patellar eversion and knee flexion to 90°. The liner was then removed. After placing the retractors in the appropriate sites, we observed that the lateral collateral ligament, arcuate ligament, and popliteus tendon were severely torn, with inadequate release of the medial structures, including the medial collateral ligament (MCL) and intact medial sleeve with pes anserine tendons. The tibia dislocated laterally, even in the absence of a laterally applied force. First, a periosteal elevator was used to strip the superficial MCL from the proximal tibia, up to the diaphyseal region. Subsequently, the insertion of the pes anserine tendon was released with a cautery. The posterior capsule was released from the top of the tibia and the back of the posteromedial femur with an electrocautery and the curved tip of the os",
"role": "user"
},
{
"content": " teotome, respectively. A second incision was made, extending from the lateral femoral condyle <|endoftext|>",
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[
{
"content": "In May, 2015, a 61-year-old right-handed woman presented at our clinic complaining of dull right posterior",
"role": "user"
},
{
"content": " pain and intermittent radiating pain from the shoulder to the anterior aspect of the upper extremity with <|endoftext|>",
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}
]
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[
{
"content": "A 5-year-old girl was referred to our hospital for the investigation of urinary incontinence. The patient had continuous low volume urine leakage requiring 4–5 daily pads. The parents could not specify whether there was any connection with standing, coughing, or effort and she had no urge to void.\nShe was constantly wet but had normal voiding habits. On initial physical examination the external genitalia appeared normal with no vaginal pooling of urine or ectopic ureteral orifice. However, a long-term external genitalia examination revealed normal urethral and vaginal openings, with an intermittent urine leakage through the vaginal orifice, which slightly increased in abdominal pressure.\nIn her past history she had recurrent febrile urinary tract infections (UTIs) since her infancy. At the age of 3 she underwent an abdominal ultrasound that suspected a double left kidney. A voiding cystourethrogram (VCUG) was performed and a vesicoureteral reflux (VUR) grade III on the right kidney was found. She was given chronic chemoprophylaxis without any UTI recurrence. She had a good toilet training and gave up daytime diapers around the age of 3. At this moment parents noticed the urinary incontinence, but this didn't bother them. At the age of 4 parents asked a urologist for help, who considered the symptoms to be the result of an overactive bladder and anticholinergic treatment was recommended. No improvement was noticed, and",
"role": "user"
},
{
"content": " for this reason the little girl was sent to our department for further investigation. Complete blood count, biochemical <|endoftext|>",
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{
"content": "-CASE 1\nA 72 years-old woman presented history of oral squamous cell carcinoma located in anterior floor of the mouth. 12 years earlier she underwent surgery, including marginal mandibulectomy, neck disection, and reconstruction using a radial fasciocutaneous free flap. She also received 70 Gy of postoperative radiotherapy. Four years later",
"role": "user"
},
{
"content": " , an anterior iliac crest bone grafting was performed to gain mandibular vertical dimension. Five dental implants were inserted in the interforaminal area of the mandible and four in the maxilla (external hex connection). The patient’s quality of life improved significally after the implant supported rehabilitation.\nEleven years after the implant loading, she complained about discomfort and gingival swelling around the chin. Clinical examination revealed mucositis and purulent exudate from two implant sites. The panoramic X-ray showed a significant loss of bone around three anterior mandibular implants (Fig. ).\nThe prosthesis was temporarily removed with one lost implant. A few days later, she reported increased pain and local crepitation. X-Ray confirmed a mandibular midline fracture at the site of the removed dental implant.\n-Treatment: An open reduction and internal fixation (ORIF) under general anesthesia was performed by extraoral approach. The prothesis was used to guide the reduction and fixation of the fracture by means of a titanium reconstruction plate (Fig. ). At this time the patient was under treatment for another second primary tumor in the rectus. Bone graft was not considered because of the infected tissue. The patient was discharged 3 days postoperatory uneventfully wearing her prosthesis adjusted to the new situation. A submandibular fistula was observed at the implant failed site). Initially, the patient and family declined any further surgeries and remained stable for two years. No periimplant bone loss was observed around maxillary implants. Because of the persistent fistula we performed an osteocutaneous fibula flap. The patient died because of lung metastases few months after this last surgery.\n-CASE 2\nA 63-year-old- <|endoftext|>",
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[
{
"content": "The patient was a 66-year-old Caucasian man, who presented for a neuropsychological evaluation performed at the Centre of Alzheimer’s Evaluation Unit (AEU), with a Mini-Mental State Examination (",
"role": "user"
},
{
"content": " MMSE) value of 18/30. The neuropsychological final report, as authentically quoted and faithfully pursuant to the description <|endoftext|>",
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]
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[
{
"content": "A 55-year-old female reported with a chief complaint of pain in the lower right side of the face for 4 months and ",
"role": "user"
},
{
"content": " swelling in the same region for 2 months. She was prescribed analgesics and antibiotics by <|endoftext|>",
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}
]
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[
{
"content": "A 49-year-old Chinese female was admitted to the emergency department of other center for a sudden severe headache, and she was successfully referred to our institution after an enhanced CT scan and a magnetic resonance (MR) showing a round hemorrhagic mass lesion. The mass of 6 cm × 4.8 cm × 6 cm was located in the left deep frontal region with an irregular peripheral enhancement and perilesional edema determining a contralateral midline shift of 8 mm []. The clinical history revealed two previous episodes of a mild headache (2 months before) and a tubal ligation performed several years before.\nAt the admission, the patient was awake, alert, with a GCS score of 15 and a moderate right hemiparesis. No cranial nerve palsy was observed. Desametasone 8 mg twice/day, mannitol 125 ml, levetiracetam 500 mg, and pantoprazole 40 mg were administered.\nThe patient underwent a surgical intervention for the excision of the lesion 2 days later. After the dural opening, some ectatic pathological cortical veins were observed within the left upper Sylvian area, in the fronto-opercular region, close to the Broca's area. The arachnoid was dissected along the margin of the vessels and after the left frontal inferior sulcus was widened a polylobate, capsulated vascular mass was detected, which was surrounded by coagulated blood. A circumferential dissection of the capsule was performed, the mass was completely removed and the specimen sent to our pathology department for histologic examination. The postoperative computed tomography (CT) scan sh",
"role": "user"
},
{
"content": " owed no tomographic alterations.\nThe histological examination was performed with hematoxylin and eosin section [] revealed ectatic and fragmented vascular structures. These findings were suggestive for a cavernous malformation.\nThe postoperative course was regular. No complications occurred, and the patient was discharged 6 days later with a good neurological outcome and improvement of the moderate right hemiparesis. A 2 months’ MR follow-up was performed []. <|endoftext|>",
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[
{
"content": "A 23-year-old male presented with complaints of progressive facial asymmetry, difficulty in speech and mastication secondary to restricted movement of th",
"role": "user"
},
{
"content": " e mandible []. The patient also experienced intermittent pain in <|endoftext|>",
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[
{
"content": "Patient n. 2 was a 60-year old female, diagnosed with suffering from POAG for ten years, under treatment with hypotensive drugs and regularly controlled IOP twice a year which appeared maintained within normal ranges. During a control visit in January 2016, the patient had reported irritating symptoms of eye discomfort, described as burning, itchiness, and feeling sand, mainly in her right eye (RE), over the last six months. The situation had been managed with the use of several types of tear substitutes, none of them successful in symptom relief. Symptoms were scored in the RE as OSDI of 74 out of 100 and a VAS score of pain of 85 mm out of 100. In the left eye (LE) the symptoms were defined by the patients as light and acceptable: OSDI score was 22 out of 100 and VAS 21 mm out of 100. Slit lamp evaluation had not shown epithelial damage, and there were no signs of inflammation, but only a reduced Tear Film Break-Up Time (TFBUT) of 4 seconds in RE and 8 seconds in LE had been recorded. A therapy with hyaluronic acid (HA) based tear substitute to be administered 4 times/day in both eyes was prescribed.\nIn March 2016, the patient was proposed to receive in her RE a treatment with topical CBS, as a compassionate unconventional therapy, with the aim to reduce the pain symptoms for which the previous therapeutic attempts ",
"role": "user"
},
{
"content": " had turned to be unsuccessful. The therapy for the contralateral LE was maintained with HA <|endoftext|>",
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[
{
"content": "A 38-year-old man with past history of hypertension was admitted for a lumbosacral spine surgery. He had been taking Valsartan 160 mg a day for the past 4 years. He underwent two uneventful previous surgeries before diagnosis of hypertension and was not known to have prior drug intolerance or atopy with unremarkable family history. He had no history of nonsteroidal anti-inflammatory drugs in the perioperative period.\nThe patient was admitted for an elective spinal fusion surgery at L5–S1. His vital signs, airway examination, other physical examination, and laboratory tests were unremarkable. On the next day, the patient was taken to the operating room; anesthesia was induced with intravenous fentanyl and propofol, smooth tracheal intubation was done using atracurium. The patient was turned to prone position and anesthesia was maintained with isoflorane and fentanyl. The patient was given 10 mg morphine and 1 g cefazolin intraoperatively.\nAt the end of the surgery and turning the patient into supine position, we noticed severe swelling in the neck and the face including the eyes lids, the checks, and the lips, Fig. . Direct Laryngoscopy revealed an edematous tongue, floor of the mouth, glottis, and supraglottic areas without rash association. On auscultation, there were no added breath sounds with normal vital signs. The patient was kept in prone position for 305 min.\nA diagnosis of drug induced angioedema was made after exclusion of other ",
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},
{
"content": " causes and intravenous dexamethasone 10 mg, diphenhydramine 25 mg and ranitidine 50 mg were given. He was continuously monitored for progression of the edema and continued to have dexamethasone. The patient remained intubated and was transferred to the intensive care unit. The valsartan was suspected to be the precipitating factor for the angioedema and was therefore discontinued.\nThe swelling started to regress after 2 h and significantly within 24 h, Fig. . The extubation was done on the second day after a flexible fiberoptic examination <|endoftext|>",
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[
{
"content": "A 69-year-old female with diabetes, chronic hypertension, and end-stage renal disease presented with progressive ataxia and recurrent fainting spells. Three months prior to presentation she had undergone a dialysis AV fistula with left brachial artery to basilic vein transposition (BVT). The patient also reported several left upper extremity symptoms including numbness, tingling, cold fingers, cramping, and decreased fine motor skills, as well as bluish discoloration particularly on the days of dialysis. On examination, the left radial pulse was not palpable, the left hand was cold to touch, and handgrip was minimally weak. The patient had impaired left sided finger-to-nose testing and an abnormal wide-based gait.\nMagnetic Resonance Imaging with angiography (MRI/MRA) demonstrated a chronic cerebellar infarct with a hypoplastic right vertebral and basilar artery. The patient was referred to our service for further evaluation with digital subtraction angiography. First, a right subclavian artery angiogram was performed which showed occlusion of the right VA at its origin with distal reconstitution at the level of the C1 vertebral body through muscular branches of ascending cervical artery (). A left subclavian angiogram demonstrated a normal subclavian artery caliber and a stump at the origin of the left VA without distal flow (). A right common carotid angiogram demonstrated flow though the posterior communicating artery with retrograde filling of the basilar artery and left VA to its subclavian origin (Figures and ). We realized that the left VA was not occluded, and the reversal of flow seen was most likely related to steal from the patient's left arm dialysis AVF. An aortic angiogram demonstrated the overall hemodynamics (). A blood pressure cuff was then inflated on the left upper extremity to occlude flow to the ",
"role": "user"
},
{
"content": " fistula. A repeat left subclavian angiogram demonstrated <|endoftext|>",
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[
{
"content": "A 55-year-old male patient was presented to a general hospital with fever, myalgia, and persistent cough. Polymerase chain reaction testing for COVID-19 was positive and he was admitted to the hospital due to severe respiratory symptoms. The patient is a known diabetic and hypertensive with a history of a nonfunctioning pituitary macroadenoma for which he underwent an endoscopic endonasal transsphenoidal resection 11 years ago in another hospital. Pituitary tumor recurrence was documented in the available two postoperative magnetic resonance imaging (MRI) studies []. After surgery, the patient was kept on maintenance levothyroxine and hydrocortisone for panhypopituitarism.\nSix days after admission, the patient complained of severe headache and acute onset of ptosis and diminution of vision in the left eye. Ophthalmological evaluation revealed complete visual loss in the left eye, a visual acuity of 20/60 in the right eye, left oculomotor nerve palsy with ptosis, and dilated nonreactive pupil. Fundus examination revealed a pale left optic nerve head. Neurological examination was otherwise normal. Computed tomography revealed hyperdensity of the sellar and suprasellar areas. MRI was consistent with PA in a recurrent large pituitary adenoma [ and ].\nThe patient was transferred to our center and underwent an urgent endoscopic endonasal transsphenoidal surgery through which a near total excision of the tumor was achieved [ and ].\nThe procedure was performed under strict COVID-19 precautions including use of powered air purifying respirators and limited OR personnel. Intraoperative findings were similar to those usually seen in cases of PA and included dark blood mixed with purple-red adenoma tissues of variable consistencies []. It was our observation that the nasal ",
"role": "user"
},
{
"content": " mucosa was pale and separated easily from the underlying bone. We have previously observed such features in two patients who previously tested positive for COVID-19. Histopathological examination demonstrated classic features of PA.\nWithin the first 3 postoperative days, the patient had some improvement of vision <|endoftext|>",
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{
"content": "A 32-year-old male patient was diagnosed as a case of lepromatous leprosy and was on multidrug therapy (MDT) for the last 1 year. He presented to us with complaints of joint pain, swelling, and stiffness of both wrist and ankle joints for the last 2 weeks. On examination thickening and tenderness of the tendons were noted and there was no evidence of joint deformity []. However, he gave a history of recurrent crops of the tender nodular lesion during and after MDT. Magnetic resonance imaging of the right ankle joint was done for evaluation of tenosynovitis which showed small focal peritendinous fluid collection along the flexor digitorium longus tendon along with minimal fluid collection around the ankle joint. Fine-needle aspiration cytology (FNAC) was done from the affected nerve and cytology revealed the presence of foamy macrophages and acid-fast bacilli. PCR from the isolates confirmed the presence of Mycobacterium leprae. A diagnosis of leprosy presenting with tenosynovi",
"role": "user"
},
{
"content": " tis and erythema nodosum leprosum (ENL) was <|endoftext|>",
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[
{
"content": "A 44-year-old Japanese man presented to the Maxillofacial Surgery Clinic at the Tokyo Medical and Dental University, Tokyo, Japan, with reports of a hard mass and dull pain in the left mandible. His medical history was generally unremarkable, though his mandible had been accidenta",
"role": "user"
},
{
"content": " lly smashed against his young son’s head at the age of 40. No fracture was detected at the time, and no treatment was received.\nClinical examination revealed slight swelling in the left lower molar region and swelling of the left mandible. There was no disturbance of sensitivity in the left lower lip or chin, and he could move his lips normally. Radiographic examination showed large, irregular, multilocular radiolucency of the left area of mandible extending to the premolar and molar area, with no evidence of any impacted tooth (Fig. ). A computed tomography (CT) image revealed a 45 × 30 × 30 mm multilocular cystic mass in the mandible (Fig. ). An axial CT image showed thinning or partly resorption site of the buccal cortical plate. The coronal section images of the CT scan showed the mass lesion displacing the mandibular canal downward, near the inferior border. The roots of the adjacent teeth were resorbed, changing their shapes (Fig. ). The location of the teeth was not changed.\nThe initial clinical impression was an ameloblastoma, myxoma, keratocystic odontogenic tumor or another tumor type lesion.\nThe lesion was removed surgically with the buccal cortical bone and buccal mucosa in contact with the mass of the tumor. The mass fully excised intraorally under general anesthesia, and the inferior alveolar nerve in contact with the mass was preserved.\nThe resected specimen of the primary tumor was a soft, fragile, yellowish-white mass. Microscopically, tumor tissues were composed of plexiform or cord-like nests of tumor cells with round to oval nuclei and eosinophilic cytoplasm in a matrix with prominent myxoid change (Fig. ). <|endoftext|>",
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{
"content": "We detail the case of a 48-year-old man, never-smoker and non-drinker, who was referred to the Clinic of Oral and Craniomaxillofacial Surgery at the University Hospital Basel, Switzerland, by his dentist, for further evaluation of a solitary ulcer on the lower left retromolar buccal plane. The patient reported swelling of the left cheek since 5 days, mild pain while chewing, and a swelling on the buccal mucosa related to the left lower jaw since about 1 year. Fever, night sweat, and weight loss were denied. Due to his obsessive-compulsive disorder, the patient has been under psychiatric medication treatment in the past (Deroxat®, paroxetine, selective serotonin reuptake inhibitor (SSRI)), but at the point of consultation, he did not take any medication. The patient reported on his allergy to penicillin, with erythematous rash episodes in the past. The data set includes the medical record of our TUGSE case including the corresponding photo material. No risk for third parties existed. Informed consent was obtained from the patient for case description and photo material.\nExtraoral examination showed a slight swelling of the cheek on the left side without redness. Palpation of the cervical lymph nodes revealed a slightly enlarged submandibular lymph node at level Ib on the left side, with a 2 × 1.5 cm diameter. Palpation of the immovable lymph node was painful. The nuchal, the axillary, the cubital, and the inguinal lymph nodes were not swollen. The diameter of the intraoral lesion on the lower left retromolar buccal plane was approximately 4 × 3 cm; the lesion presented as indurated base with a central superficial ulceration of 2 × 1 cm (Fig. ). The rapid growth of the ulcer over the last 5 days was potentially indicative for a malignant proc",
"role": "user"
},
{
"content": " ess, wherefore we performed an incisional biopsy to obtain histopathological diagnosis after we <|endoftext|>",
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]
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[
{
"content": "An 8-month-old female infant had coronary reimplanta",
"role": "user"
},
{
"content": " tion at <|endoftext|>",
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[
{
"content": "A 41-year-old man with known metastasis to the adrenal glands and the second part of the duodenum close to the ampulla of Vater from clear cell renal cell carcinoma (ccRCC) was admitted to our d",
"role": "user"
},
{
"content": " epartment due to massive gastrointestinal bleeding. The patient had undergone left nephrectomy one <|endoftext|>",
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}
]
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[
{
"content": "A 70-year-old male patient was presented to us with a huge swelling measuring 35 cms in greater dimension arising anteriorly from the neck more on the left side which was hanging up to the umbilicus (). The swelling was painless, slow growing and had acquired the present size in approximately 20 years. There was no history of treatment in the past. Patient was completely asymptomatic, except for ulceration of the overlying skin. On palpation, the swelling was smooth, painless and non-tender. Skin over the swelling was stretched, shiny and showed ulceration over the lower most part. There was no lymphadenopathy or any other palpable mass.\nENT examination of the patient was normal. Thyroid hormonal evaluation showed no abnormality. On ultrasound, the “mass” was iso",
"role": "user"
},
{
"content": " -echoic with subcutaneous fat. It laid in front of the left lobe of the thyroid which was normal in size and echogenicity and moved freely with swallowing under the mass. The mass appeared to have an ill-defined capsule with several thin echogenic septa seen coursing through the substance of the mass. The ultrasound findings were suggestive of a soft tissue lesion. Computed tomography (CT) scan of the neck showed a hypodense mass in the left side of the neck with fat density, measuring 17×9 cm with multiple internal septations.\nIt originated in the left anterior triangle of the neck and extended up to the upper chest cavity. The mass was seen to be causing mild pressure effects with displacement of left parapharyngeal and oropharyngeal spaces. The trachea and the major vessels were displaced to the right and both the lobes of the thyroid seemed normal. Findings were suggestive of a soft tissue lesion possibly lipoma. A fine needle aspiration was performed and samples were taken from multiple levels of the swelling for adequate and representative cytological material.\nAll cytological smears yielded mature adipose tissue fragments. In view of ultra-sonographic finding and CT evaluation, a diagnosis of giant subcutaneous lipoma of neck was made <|endoftext|>",
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[
{
"content": "A 56-year-old male construction worker presented to the emergency department with a two-week history of low back pain followed by left shoulder decreased range of motion and left wrist and ankle pain, in addition to associated fever and chills for two days. One week prior to his presentation, the patient sought medical advice for his back pain at an outpatient clinic; he was given a primary diagnosis of mechanical low back pain and his primary care physician referred him to physiotherapy. The patient had no history of a recent upper respiratory tract, gastrointestinal tract, or urinary tract infection. There was no history of recent travel, steroid use, or intravenous drug abuse. He denied alcohol abuse and smoking. Past medical history revealed dyslipidemia, as well as a previously drained perianal abscess two years before which was complicated by a fistula that was treated surgically one year prior to presentation.\nUpon the patient's arrival to the emergency department, a temperature of 38.8°C was recorded and he was hemodynamically stable. Physical examination demonstrated low back tenderness and left shoulder swelling with limited and painful range of motion. His left wrist and ankle exam also showed decreased range of motion secondary to pain with moderate effusion. Cardiac examination did not reveal any murmurs. The neurological examination showed intact cranial nerves. His upper extremity neurological exam was unremarkable, but his lower extremity examination showed weakness of his right hip flexors and right knee extensors in comparison to the contralateral side (4/5). He had normal sensation and his biceps, triceps, and ankle reflexes were all normal.\nNo other foci of infection upon physical examination were noted.\nLaboratory data revealed an elevated erythrocyte sedimentation rate (76 mm), an elevated C-reactive protein (420 mg/dL), and a white blood cell count of 17,000/mm3 (80% segmented neutrophils). Aspiration of the left shoulder returned purulent frank pus containing 148,000 leukocytes/mm3",
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"content": " with 80% neutrophils, <|endoftext|>",
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"content": "A 60-year-old man was referred to our clinic presenting with 14-month history of persisting unilateral pulsatile tinnitus. He had no history of craniotomy, trauma and did not complain various other neurologic symptoms. Otoscopic examination, audiometry, and tympanometry showed normal finding. Physical examination by stethoscope revealed a pulsatile sound behind the left ear, about 2 cm above the mastoid process. Tinnitus Handicap Inventory (THI) quantitative questionnaire was performed by the patient, which scored 52 points. The patient complained high pitch sound like whistle regularly depend on his position. Manual compression in the left side of the neck and mastoid process led the noise to cease. An initial magnetic resonance imaging (MRI) with magnetic resonance angiography (MRA) demonstrated the suspicious left transverse venous sinus arteriovenous fistula (). Since MRA findings showed a suggestive DAVF, catheter angiography was obtained revealing abnormal vasculture along branches of posterior and middle meningeal artery, basal tentorial artery and early filling of the transverse/sigmoid sinus, which confirmed the diagnosis of DAVF (). Because there was no risk of neurological complications such as increased intracranial pressure, cerebral hemorrhage, focal neurological symptoms, we decided to wait until the fistula could be occluded spontaneously instead of endovascular embolization. Thus, we tried to compress the neck intermittently to help self occlusion. The patient was educated to conduct the dual compression of the carotid artery and ",
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"content": " jugular vein with seating position, above the neck carotid bifurcation with 2-4 fingers as a power of the flow sounds disappeared. The daily compression was applied 20-30 times for 10s each time. There were no side effects during manual compression, and the patient did not feel discomfort as he understood the manual compression well. And the patients were followed up every 3 months and the THI score and qualitative questionnaire were surveyed. After 1 month of external manual compression without further treatment, he reported resolution of pulsatile tinnitus and we could not observe any tinnitus sound by stethoscope. <|endoftext|>",
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"content": "A 22-year-old female in her first pregnancy was referred for fetal echocardiography at 30 weeks of gestation. The fetal echocardiogram revealed discordant atrioventricular connections with pulmonary atresia and a small ventricular septal defect. Delivery at a cardiac center was recommended. The baby was born by normal vaginal delivery at term and weighed 2.46 kg. The perinatal period was uneventful. The saturation of oxygen in room air was 86%. The cardiac impulse was palpable in the right hemithorax, the second heart sound was single, and a continuous murmur was heard in the infraclavicular region. On the frontal chest radiograph, the heart was noted to occupy the right hemithorax []. The stomach bubble was visible on the left, with the liver shadow on the right side. The electrocardiogram was consistent with usual atrial arrangement.\nA detailed echocardiogram was obtained postnatally. The abdominal aorta was present to the left of the spine, with the inferior caval vein to the right. The heart was right sided, with the apex pointing to the right. The systemic veins drained into the right-sided atrium, while all four pulmonary veins drained into the left-sided atrium. The atrioventricular connections were discordant. The left-sided tricuspid valve was morphologically normal and competent, and the left-sided morphologically right ventricle showed normal systolic function. It gave rise to both arterial roots, but with pulmonary atresia []. Thus, the aorta arose anteriorly and to the left of the atretic pulmonary trunk, which was aligned with the cavity of the morphologically right ventricle. The pulmonary root was small but well formed. The aortic outflow tract was unobstructed. Confluent but mildly hypoplastic pulmonary arteries were supplied by a vertical and tortuous",
"role": "user"
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"content": " persistent arterial duct, which originated from the underside of the aortic <|endoftext|>",
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{
"content": "A 45-year-old male patient came to the department with the chief complaint of loose teeth in upper and lower front jaw regions since 1 year w",
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{
"content": " ith swollen and bleeding gums. Patient first noted bead like nodular growth over the gums which progressively enlarged to the present size covering almost entire teeth interfering with further cleaning of teeth.\nThe patient was hypertensive since 1.5 years and was under medication Coronol-AM (atenolol, 50 mg + amlodipine, 5 mg) once daily. He denied the history of any adverse habits.\nThe patient was moderately built and nourished with no signs of anaemia and jaundice and noncyanosed. His vital signs were within the normal range.\nIntraoral examination revealed generalized enlargement of attached gingival extending up to marginal and interdental gingiva. Surface of the gingiva appears lobulated with loss of scalloping (). Poor oral hygiene status of patient was assessed by the presence of local irritating factors which surrounded the teeth.\nBased on drug history and clinical examination of the patient provisional diagnosis of combined gingival enlargement was made. Complete hemogram of the patient was done, but all the parameters were within the normal range. Orthopantomogram was taken which revealed generalized bone loss ().\nAfter this, incisional biopsy was done. Histopathological report revealed few areas of hyperplastic orthokeratinized and parakeratinised stratified squamous epithelium and connective tissue exhibiting mixture of dense and loose fibrous component. Inflammatory cell infiltrate with PMLs and dilated blood capillaries with few areas of calcifications were also evident.\nCorrelating history, clinical examination, and investigations, final diagnosis of combined gingival enlargement (amlodipine induced and inflammatory) was made. Patient was referred to periodontics department for further treatment. In the preliminary phase, extraction of teeth (11, 21, 22, 23, 31, 32, and 34) with hopeless prognosis was recommended. Planned sessions of scaling and root planning with drug change with the patient's physician consent were performed. Patient <|endoftext|>",
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"content": "A 38-year-old Hispanic male was admitted to Los Angeles County + University of Southern California Medical Center after sustaining a single stab wound to the left chest. Upon arrival the patient was bradycardic with a systolic blood pressure of 50 mmHg, and Glasgow Coma Scale (GCS) score of 3. The patient underwent simultaneous intravenous access, oral intubation and resuscitative left thoracotomy. After evacuation of 400 ml of blood and clot from the chest a pericardial wound was noted anterior to the phrenic nerve. The cardiac tamponade was rapidly decompressed and cardiac arrest was noted. A cardiac wound in the left ventricle was repaired using a 2.0 polypropylene suture. An aortic cross-clamp was applied. Cardiac massage along with intracardiac injection of epinephrine and bicarbonate resulted in sinus tachycardia. Four additional sutures were required upon restoration of sinus tachycardia to control an exsanguination in the emergency department as the full extent of the defect was not evident during asystole. Residual ",
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"content": " hemorrhage was present when the patient was taken to the operating room (OR) for definitive repair. In the OR, the cardiac wound was reinforced with four pledgeted polypropylene mattress sutures with no residual hemorrhage. Nevertheless, the left ventricular wall appeared edematous and bruised after the complex repair. The pericardium was left open. The patient continued to be hypothermic, acidotic and coagulopathic. Attempted chest closure resulted in severe bradycardia and therefore, temporary closure was obtained with a vacuum-assisted closure device and the patient was transferred to the surgical intensive care unit. In total, 24 units of packed red cells, 10 units of fresh frozen plasma, and 6 units of platelets were transfused. On the second postoperative day, chest was uneventfully closed in the OR. The early hospital course was complicated by acute renal failure (peak creatinine 6.19 mg/dL) requiring dialysis. The patient was extubated on hospital day (HD) 10 with no neurological impairment. On HD 24 a cardiac ultrasound was obtained revealing <|endoftext|>",
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"content": "A four-year-old boy presented with complaints of recurrent epistaxis and a bony white mass in the right nostril, in November 2020. The child’s mother initially noticed a small intranasal mass in March 2020, which she said has gradually increased to the current noticeable size. She did not visit a hospital earlier because of the coronavirus disease-19 (COVID-19) pandemic. However, the epistaxis episodes became frequent in the last few days. The child’s mother gave a history of loss of a maxillary central incisor following a dental trauma in November 2019, due to a fall. The mother was not able to find the tooth and ",
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{
"content": " was considered lost. <|endoftext|>",
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{
"content": "A male famer aged 68 years old was admitted to our institute for a tumor in his lower lip. This patient has a history of smoking (30 pack-year) and consuming alcohol for more than 30 years (approximately 200 ml per day). He was diagnosed as systemic lupus erythematosus (SLE) 20 years ago and had been treated with methylprednisolone for 17 years. For the last three years, his SLE status has been stable and thus, he discontinued the SLE treatment.\nThe patient reported that the tumor in the middle of his lower lip had appeared for a year and gradually increased in size without any pain or bleeding. He did not receive any treatme",
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{
"content": " nt because of his financial issue. For the last few months, the tumor had rapidly grown, bled and become painful, so that he could not eat or clean his teeth.\nOn examination, there was a 3 x 4 cm, raised, ulcerous, and bleeding tumor, developing in the lower lip and expanding to 1/3 external upper lip (). The submental lymph node was around 2 cm in diameter, firm, and hardly moveable. Ultrasound revealed a suspected metastatic submental lymph node with absent echogenic hilum. MRI Scan demonstrated a lesion in lower lip with size of 13 x 31 mm, which increased in T1W signal and T2W signal, strongly enhanced after contrast and did not invade surrounding tissue. A 2 cm and round lymph node was also identified (). The fine needle aspiration (FNA) result of the lymph node presented a metastatic squamous cell carcinoma and the biopsy result of the tumor confirmed squamous cell carcinoma (SCC). No abnormality was detected by a metastatic work-up. Therefore, the clinical staging of this patient was cT2N1M0. In addition, other para-clinical tests including full blood count, biochemistry profile, ds-DNA, ANA were normal, which indicated a stable status of SLE.\nThe patient underwent surgery including a complete removal of the lower lip and 1/3 external <|endoftext|>",
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{
"content": "A 26-year-old, otherwise healthy male has reported to the restorative cli",
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"content": " nic at Al-Farabi College, Riyadh for investigation and management of pain affecting the posterior left region of the maxilla. His history of chief complaint showed typical presentation of severe pain due to advanced buccal cervical carious lesion.\nBased on clinical findings, radiographic interpretation, and vitality tests, a diagnosis of acute pulpitis of upper left first molar was made. No periapical diagnosis was identified. Routine endodontic therapy was planned. Local anesthesia using 2% lignocaine with 1:80,000 epinephrine was administered. Standard routine root canal procedure was performed under rubber dam isolation. The carious lesion was removed and replaced by composite material (Filtek™ P90, 3M). The endodontic access opening was prepared. Working length was established. In addition, cleaning and shaping were performed using crown down technique with ProTaper rotary instruments (dentsply). In addition, obturation was done with lateral compaction. A root canal completion radiograph confirmed the correct root canal therapy. A single dose of 600 mg ibuprofen was prescribed to control postendodontic pain. The patient reported to has an increased erectile function and libido after 2 h from taking the ibuprofen tablet. He has reported that has done three sexual intercourses with his wife at that day. On the next day, he was curious, and he repeated taking the ibuprofen tablet. Surprisingly, he had the same experience of his first use of ibuprofen of having increased libido and erectile function that has lasted for at nearly 6 h. He contacted us to question this unusual experience. His medical history was re-reviewed thoroughly with an endocrinologist, and nothing was mentioned. Furthermore, tests for complete blood count, testosterone, thyroid stimulating hormone, cholesterol pre and post ibuprofen intake were assessed, and all results came up as normal. He also reported to have the same previous experience during the test period. A gynecological ultrasound test was also <|endoftext|>",
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{
"content": "A 46-year-old man also reported exercise/activity-related pain and fatigue from early childhood. As patient 1, he was always considered to be “a lazy child”. He was not able to run and physical activities such as walking or swimming were challenging. As a child he reported trying to build a good relationship with his physical education teachers, so they would feel pity for him and he could avoid any strenuous physical activities (PA). He experienced three severe episodes of rhabdomyolyses in his life. The first one happened during childhood, which followed vigorous physical activities. The second rhabdomyolysis episode was at the age of 18 following multiple squats, which he performed during a physical test for military service. Not qualifying for the military service, instead he had to complete a civilian service at the university hospital at the age of 22. As he was clearly weaker than his colleagues, a diagnostic investigation took place, which included a skeletal muscle biopsy. At that time, doctors advised him to avoid excessive physical effort. He was told about the second wind phenomenon; however, it was not explained how to reach it. Additionally, he was recommended to eat a maximum of 20% of his daily food intake in carbohydrates. However, the rest of the macronutrients recommendations were not specified. In the following years, his physical activity level decreased, leading to physical deconditioning, loss of muscle mass, and increase in fatty adipose tissue and body weight.\nThe third rhabdomyolysis episode was experienced one year ago and w",
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{
"content": " as nearly fatal. He was undergoing physical assessment for <|endoftext|>",
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{
"content": "ENDOMETRIAL CANCER . PROCEDURES TOTAL ABDOMINAL HYSTERECTOMY AND BILATERAL SALPINGO-OOPHORECTOMY HISTORY OF PRESENT ILLNESS This is a 48-year-old G 3 P 3 who prese",
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{
"content": " nted to Dr. Fuscmadril <|endoftext|>",
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{
"content": "An 83-year-old female presented to the emergency department secondary to an accident involving her wheelchair. Earlier that day she had been seen by her family physician regarding a subcutaneous abscess located on her abdomen and was on her way to see a general surgeon when she had an accident, whereby she was flung from her wheelchair. She was fully immobilized and on a backboard. She was later taken off the backboard after passing Nexus criteria for cervical spine immobilization, with no complaints of pain other than in her left lower quadrant. After being taken off the backboard, a full physical examination was performed. The patient's vital signs were blood pressure of 124/59, heart rate of 107, respiratory rate of 18, temperature of 97.5°F, and a pulse oximetry of 95% on room air. Auscultation of lungs found them to be clear bilaterally in all fields; cardiac auscultation found normal S1 and S2 with no murmurs, gallops, or rubs. Upon examining the patient's abdomen, b",
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"content": " owel sounds <|endoftext|>",
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{
"content": "A 38-year-old woman with a 3-year history of cholecystolithiasis was examined at a local hospital and referred to our hospital for endoscopic gallstone removal without gallbladder excision. When she was hospitalized at our hospital, the acute right upper abdominal pain had persisted for two hours.\nOn physical examination, no signs of jaundice were seen in the skin or sclera. The patient's abdomen was soft, with no sign of lumps, with tenderness other than rebound tenderness in the gallbladder area. Murphy's sign was positive. Ultrasonography revealed several movable masses of 7 × 10 mm and 7 × 9 mm in size, which were strongly echogenic, with acoustic shadowing in the body of the gallbladder; an immovable strongly echogenic mass of 7 × 10 mm with acoustic shadowing in the neck of gallbladder and cystic duct; and poor sound penetration and a dense, low-light spot in the dark space of the bile. There was no thickening of the gallbladder wall. The gallbladder emptying index was 30%. No obvious abnormalities were seen in the liver, spleen or pancreas.\nThe patient was diagnosed as having cholecystolithiasis complicating acute cholecystitis and incomplete biliary-tract obstruction. The patient had been given anti-inflammatory treatment after the examination for 2 weeks and the symptoms of acute cholecystitis had disappeared before the operation was schedule, and the patient was strongly in favor of preserving the gallblad",
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{
"content": " der. Consequently, after approval by the medical ethics committee and provision of informed consent by the <|endoftext|>",
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{
"content": "A 29 years old pregnant patient with singleton pregnancy at 38th gestational week (GW) was admitted to our obstetric emergency room for membrane rupture. She referred to be affected by a giant, congenital AVM of the left chest wall, extending from the third to the seventh thoracic interspace, involving the overlying thoracic muscles and the correspondent thoracic nerves, the rib cage, the parietal pleura, the transverse process of seventh thoracic vertebra and the scapular girdle, with severe neuropathic pain and reduced mobility in her left arm. She underwent to multiple embolizations to treat the lesion, with no or mild improvement of her pain despite she was taking 60 mg Oral Morphine Equivalents (OME) per day and pregabalin 300 mg twice daily. To treat her medically refractory neuropathic pain she was therefore ",
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{
"content": " referred for SCS system implant. A Model SC-1200 Precision™ Montage™ Magnetic <|endoftext|>",
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{
"content": "A 38-year-old African American female presented to the emergency department for chest pain. The patient's past medical history was significant for hypertension, for which she had not taken her lisinopril for about 2 years, and diabetes, controlled with diet. Additionally, the patient had a history of smoking for 20 years and had quit about 3 months prior to admission; however, 1 week prior to the onset of chest pain, the patient was started on oral bupropion 150 mg every morning for smoking cessation for tobacco cravings. In the emergency department, the patient received aspirin chewable 162 mg by mouth and 3 sublingual nitroglycerin tablets, which relieved the chest pain, and was admitted to the general medicine floor in order to rule out an acute coronary syndrome. The next day, prior to her stress test, the patient went to the cardiology clinic, where she became confused and began talking about demons and auras. The patient's husband noted that this behavior was strange, and the patient was escorted back to the medical unit. On the medical floor, the patient was requesting to be examined by a female because having a male examine her would be “inappropriate” because “together (they) are the body of Christ.”\nThe patient was evaluated by psychiatry, and the patient's husband provided further insight into the patient's bizarre behavior. According to the patient's husband, the patient started acting strange w",
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"content": " hen she woke up the morning before coming to the <|endoftext|>",
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[
{
"content": "The patient was a 65-year-old man with a prior history of repeated plastic",
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},
{
"content": " surgery for scar contracture of the hands and fingers, ablation surgery for idiopathic ventricular tachycardia, and diabetes. There <|endoftext|>",
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[
{
"content": "A 49-year-old Caucasian male was evaluated at the Department of Adult Psychiatry Intensive Outpatient (IOP) Treatment Program for initial intake after having been referred from the Department of Neurology Outpatient Clinic. He had complaints of depressed mood, lack of enjoyment of pleasurable activities, sleep disturbances, poor concentration, and occasional passive suicidal thoughts. These symptoms were in association with ongoing progression of symptoms related to his diagnosis of SCA1. His neurologic symptoms included coordination problems and ataxia initially at diagnosis, but in recent years speech impairment, swallowing difficulties, some spasticity, and eventually muscle atrophy were presented. He had to utilize a motorized wheelchair as a result of his progressive disability. His current house was not fully wheelchair accessible. He lived alone but had siblings who visited at least several times per week. He also seemed to lack insight into the relationship between his thoughts, feelings, and physical limitations.\nAt the psychiatric evaluation, he expressed that his self-esteem was strongly affected by his limited physical mobility due to his SCA1, and he seemed extremely unhappy. He reported passive death wishes at least once a week, usually without a suicidal plan or intent. Laboratory evaluations including hemogram, liver function tests, total protein, vitamin B12, folic acid, T3, T4, and TSH were within normal limits. Baseline psychiatric evaluation with the Beck Depression Inventory (BDI-II) [] revealed scores of 23 (moderate depression). According to clinical evaluation as well as DSM-V [] criteria, the patient was diagnosed ",
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{
"content": " with major depressive disorder and he was started on sertraline 50 milligrams (mg) by mouth per day. He <|endoftext|>",
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[
{
"content": "A 64-year-old Asian female was presented to our hospital with a recurrence of liver nodular lesions after multiple surgical resections.\nThe patient had received lung lobectomy due to lung cancer in the right upper lobe 11 years ago (). Postoperative pathology showed a 4.0×3.9 × 3.0 cm moderately differentiated adenocarcinoma, with one positive mediastinal lymph node among all the 10 dissected lymph nodes (). She quit adjuvant chemotherapy after one cycle due to intolerance. No elevation of tumor markers had been reported perioperatively.\nSeven years ago, the patient developed jaundice. CT assessment showed a pancreatic head mass with involvement of the distal common bile duct (). Results of tumor markers including CA19-9 were negative. She was then treated with radical pancreaticoduodenectomy, where a 2.5×2.0 × 2.0 cm moderately differentiated adenocarcinoma with negative lymph node metastasis was removed (). Afterward, she received adjuvant S-1 chemotherapy (consisting of tegafur 40 mg, gimeracil 11.6 mg, and oteracil 39.2 mg, administered orally twice a day) for 3 cycles (2 weeks per cycle followed by a one-week rest period), which was also discontinued due to adverse events.\nThe patient was then put on surveillance with an annual imaging assessment. Four years after the Whipple procedure, a follow-up examination showed a solitary liver lesion in segment VII (). She refused interventional treatment or chemoth",
"role": "user"
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{
"content": " erapy and chose cytoreductive surgery to resect the segment VII lesion. Postoperative <|endoftext|>",
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[
{
"content": "A 30-year-old male patient presented to our hospital with pain in the left hip region, reduced leg mobility due to theleft hip PJI with two fistulas in the upper lateral and anterior thigh region. Collecting anamnesis, the patient had a left distal femoral metaphyseal fracture due to a fall at the age of 10. At that time, X-rays showed dysplastic bone lesions of the left femur and the patient was diagnosed with monostotic FD. The patient had distal femoral osteosynthesis with a dynamic compression plate. The fracture healed without any complications. The plate was evacuated 1 year later and the dysplastic bone lesions were sealed with a bone allotransplant. Ten years later, the patient had a pathological left femoral neck fracture without any trauma. Osteosynthesis with intramedullary femoral nail was performed in another hospital. Six weeks after the operation, the patient developed growing pain and swelling in the left hip and distal thigh region. Septic arthritis of the left hip joint was diagnosed. The intramedullary nail was removed, femoral head resected, and the patient received systemic antibiotic therapy for 6 weeks. Afterward, debridement of the distal femoral metaphysis was performed, and bony cavities were sealed with bone graft substitute made of calcium sulfate. After 8 weeks, there were no signs of active infection and the patient over went total left hip arthroplasty with anuncemented prosthesis. Three",
"role": "user"
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{
"content": " years later, the patient developed a PJI. Local debridement, removal of the <|endoftext|>",
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{
"content": "A 64-year-old man, who underwent total arch replacement with J graft open stent graft (21 mm×60 mm) for ATA AD 2 years previously, was admitted to the hospital due to enlargement of remaining descending aorta. Computed tomography (CT) revealed aortic dissection from the distal anastomosis site to the renal artery. The diameter of the distal aortic arch was 65 mm and the descending aorta above the diaphragm was 35 mm (). Adamkiewicz artery was detected at Th 10. Echocardiography showed an ejection fraction of 70% with no remarkable valvular dysfunction. He was planned for descending aortic replacement.\nCerebrospinal fluid drainage was placed 1 day before the operation. He was placed on a right lateral decubitus position. Left thoracotomy through the fourth intercostal space was performed to expose the descending aorta. However, adhesion at the previous distal anastomosis site was severe, thus complete dissection of the adhesion was not performed. The right axillary artery and right femoral artery were exposed for a",
"role": "user"
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{
"content": " rterial cannulation and the right femoral vein was exposed for venous cannulation. The <|endoftext|>",
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{
"content": "A 13-year-old Caucasian male sustained diaphyseal fractures of the left radius and ulna three months prior to the presentation in focus. The fractures were managed surgically with closed reduction and 3.0 mm intramedullary elastic nailing of the ulna and open reduction and internal fixation (ORIF) of the radius with a 3.5 mm dynamic compression plate (DCP). Follow-up at two months confirmed satisfactory progress and radiological evidence of the union. The patient was scheduled for elective removal of the elastic nail at three months.\nOne week prior to metalwork removal the patient tripped and fell onto his outstretched left hand. He presented with severe clinical deformity of the forearm and severe distal neurovascular deficit (Figure ). The hand was pale with an absent radial pulse, prolonged capillary refill time (CRT) and no digital signal on pulse oximetry. Furthermore, both sensory numbness and motor weakness in the distributions of both median and ulna nerves were noted.\nEmergent closed reduction in the emergency department was only partially successful in restori",
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"content": " ng alignment, with restoration of the <|endoftext|>",
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{
"content": "We received a 15-year-old male at our outpatient consultation with complaints of an abnormal looking scrotum and a left scrotal swelling. He denied testicular pain. His past history was notable for the presence of this scrotal anomaly from birth with several consultations done in infancy and no definitive diagnosis nor management proposed. On examination, there was a vacant, hypoplastic right hemiscrotum with no palpable right testis along its normal course; a normal looking left hemiscrotum containing a testis; an ovoid shaped mass at the left suprascrotal area which was firm, nontender and not fixed to the deep or superficial plane (Figures and ). There was no hypogastric mass, no palpable kidney mass, and no disorder of sex development. The penis was uncircumcised.\nAn abdominal ultrasound found no renal anomalies, and description of the left suprapubic mass was inconclusive. A diagnostic laparoscopy was planned to explore the right testis and any anomaly. On laparoscopic evaluation under general anesthesia, the right spermatic vessels and vas were seen going through an open right deep inguinal ring (). The spermatic vessels and vas on the left were seen traversing their",
"role": "user"
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{
"content": " corresponding closed deep inguinal ring (). There were no <|endoftext|>",
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{
"content": "Case 1 is a 37-year-old, right-handed male with left frontal glioblastoma (World Health Organization; WHO grade IV). The patient had a history of prior resection and was under consideration for additional surgery to address tumor regrowth when he received his language fMRI exam. The patient was diagnosed with moderate expressive aphasia. There was a significant loss of signal in and around the les",
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{
"content": " ion from prior resection. This signal loss was located approximately where Broca’s area should be represented. The upper panel of shows the raw fMRI. The area of prior resection was filled with the cerebral spinal fluid (bright white color). There was clear signal loss due to which the functional cortex associated with Broca’s area could not be observed (the lower panel of ).\nAn infiltrating nature of the tumor, as well as the patient’s expressive language deficits may have further disrupted language activation in this region. The patient displayed increased activation of the motor cortex, including the insular motor area in the right hemisphere, bilateral activation of the tongue motor area, and medial pre-motor activation to the right of midline consistent with the supplementary speech motor area and speech motor area proper activation. These elevated motor activations might be interpreted as compensatory mechanisms following the language deficits (see for details). While no language activity was noticed in Broca’s region, eloquent language sites were reported in this area during subsequent intraoperative language mapping both cortically and sub-cortically (because of the infiltrative nature of the patient’s tumor, resection was carried out, while the patient engaged in ongoing language testing). In sum, numerous confounding factors may have contributed to disrupted fMRI language dominance in Case 1: an anterior tumor location affecting both the grey and white matter, high tumor grade, likely adult (more recent) onset, large tumor volume, infiltrating nature of the tumor, aphasia, prior surgery, and seizures. summarizes the confounding and modulating factors for Case 1. <|endoftext|>",
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"content": "This is a 39-year-old male with a past medical history of coronary artery disease requiring coronary artery bypass graft in 2009 and percutaneous coronary intervention and stenting in 2008 to the left anterior descending artery and right coronary artery. Patient also has hypercholesterolemia and hypothyroidism. He presented to the emergency department complaining of substernal chest pain associated with dizziness and shortness of breath. This occurred once to two times a week. His last stress test was in 2013 which was insignificant. One month ago he saw his cardiologist who recommended using nitroglycerin more frequently. His chest pain initially improved but for the past week his pain was increasing in severity and radiating to the left shoulder. Patient denied any nausea, vomiting, sweating, or",
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},
{
"content": " loss of consciousness. The chest pain was not aggravated or alleviated by position or medication. Vital signs were within normal limits. Physical examination was normal including cardiac and neurological exam. The patient was seen by the cardiac team and was scheduled for a cardiac catheterization.\nA cardiac catheterization was performed which did not show any narrowing or disease of vessels. His ejection fraction was 65% and the previous grafts and stent were patent. The cardiac team cleared the patient for discharge. The patient was scheduled for discharge, however he suddenly developed left-sided weakness and facial droop. NIH stroke scale was 9. The rapid response team was called and the patient underwent a CT scan with no contrast which showed no evidence of any acute or significant intracranial abnormality and no bleeding. Patient was transferred to the ICU and the neurology team was consulted. Neurology recommended the use of tPA as the patient was within the window period for use. While reviewing the guidelines and contraindications, it was discovered that the patient's aPTT was higher than the upper normal limit due to the recent use of unfractionated heparin for cardiac catheterization. At this time, the primary team made the decision to recheck the aPTT after one hour since the patient was still within the therapeutic window for tPA. The repeat aPTT was <|endoftext|>",
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[
{
"content": "A 19-year-old man presented to the orthopedic surgery department with pain in the left buttock after military training which including running with hyper-flexion of hip for 3 hours, twice a day for 5 days. When he hyper-flexed his left hip joint, he felt and heard a crack. Initially about one week later, he referred to the local hospital because of persisting hip pain. On radiographic evaluation, he diagnosed as pelvic bone fracture and recommended for further evaluation. However, he refused to get more examination due to the alleviation of the hip pain. Although he got rest without any military tra",
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"content": " ining for the next six weeks, there was no improvement and tingling sense developed over the posterior aspect of left thigh. During the first consultation with the patient, he complained difficulty on sustained standing and sitting on a locked position.\nHis body weight, height, hip and lumbar T-score for dual-energy x-ray absorptiometry (DXA) scan were 76 kg, 183 cm, –0.7 and –0.1 respectively. On physical examinations, there was no limitation on range of motion of the left hip joint. Also he could walk without any pain except mild tenderness on the area distal from the ischial tuberosity. On the radiographs of the pelvis anteroposterior and frog leg view (), there was a 35×40×20 mm sized bony fragment, 15 mm distance from the left ischial tuberosity. After the patient admitted to our hospital, he had an examination of computed tomography () and magnetic resonance imaging for rule out pathologic conditions. There was a bony fragment at left ischial tuberosity, which was mainly from conjoined origin of biceps femoris and semitendinosus tendons without any bone marrow edema (). Overall, he diagnosed as old avulsion fracture at ischial tuberosity. He determined to get conservative treatment on condition of a gradual alleviation of the symptom. During the admitted 2 months, he just got rest and high intensity <|endoftext|>",
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