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"content": "A 12-year-old female patient presented without any systemic problems. She had noticed a bulging in her soft palate three months earlier. The patient’s parents reported an increase in the size of the bulge two weeks previously. On intraoral examination, a mass with an ulcerated surface was noted in the soft palate. The lesion extended from the hard palate to near the uvula on the right side, was 3 cm at its largest diameter, and had an ugly appearance. The patient reported no pain, bleeding, or difficulty in swallowing or breathing ().\nAfter an incisional biopsy, closure of the wound edges was problematic. A piece of Surgicel® was fixed between the two edges of the tissue and then sutures were placed in normal mucosa far away at the edge of the lesion. Microscopically, the lesion was encapsulated and consisted of Antoni A tissue with Antoni type B regions. The Antoni A tissue includ",
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"content": " ed Verocay bodies and was marked by spindle-shaped Schwann cells <|endoftext|>",
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"content": "A 25-year-old lady presented to hospital 36 days after giving birth via an uncomplicated lower segment caesarean section. She stated that the scar was well healed since the fifth day post-surgery and she had begun breast feeding. There was no history of nipple trauma or mastitis. She complained of a 15 d",
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"content": " ay history of progressive pain, swelling and decreased range <|endoftext|>",
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"content": "A 6 years old male child born by full term vaginal delivery with a birth weight of 2.25 kg, presented with a huge asymptomatic swelling over the left lateral chest wall since 6 years. Mother noticed a small asymptomatic lump on back of the left shoulder at 1 month of age",
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"content": " , which gradually progressed to present size <|endoftext|>",
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"content": "A 63-year-old female with no comorbidities presented with gradually progressive, painless, upper abdominal distension and",
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"content": " loss of appetite for one year. <|endoftext|>",
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"content": "The patient is an 18-year-old African American male with a documented history of Prader-Willi syndrome with mild intellectual disability and type I diabetes mellitus (DM) who presented to the emergency department (ED) multiple times over the course of two months after attempting suicide via multiple methods.\nThe patient went shopping with his mother and became upset that he was not getting a high carbohydrate meal. He then became behaviorally dysregulated later on and refused to step out of the car. Later that evening, he refused to take his insulin. He was then found by his mother at nightt",
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"content": " ime somnolent and reported overdosing on his home insulin. <|endoftext|>",
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"content": "A 62-year-old right-handed man presented to our clinic for advanced treatment options for WC. He had no previous injuries of the limb, no family history of dystonia or tremor. However, he did report repetitive use of the right hand with handwriting and shooting firearms. Initial symptoms occurred in his early 30’s and were characterized by hand cramping and abnormal penmanship when writing. The symptoms were intrusive and unremitting, and over the past nine years significantly interfered with his ability to handwrite with his dominant hand. These symptoms progressed over the past 5 years impairing his ability to perform any action that involved gripping objects. Consequently, he rarely used his right hand for daily activities. He had p",
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"content": " reviously been prescribed tetrabenazine, baclofen, and <|endoftext|>",
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"content": "A 62 year-old man was admitted to Severance hospital, Seoul, Korea with a chief complaint of left shoulder pain for 2 months and melena for 1 week. He had been treated for diabetes mellitus for 3 years and had a smoking history of 30 pack-years. His medical history included esophagectomy with esophagogastrostomy due to an esophageal rupture caused by a lodged chicken bone 8 years prior. This gastric transposition was performed by the substernal route. The patient also underwent several esophageal dilations because he suffered an esophageal stricture due to lye ingestion more than 11 years ago. Upon admission, laboratory studies revealed that he had mild leukocytosis (13,800/uL) and severe anemia (Hb 5.5 g/dL). Chest radiographs showed mild pulmonary edema without evidence of pneumopericardium. On endoscopic examination, there was a huge, deeply penetrating gastric ulcer on the anterior wall of the upper body (). A gastrograffin chest CT scan was then performed, showing a focal lesion bulging out of the posterior gastric wall and protruding into the pericardial space with severe thickening of the adjacent pericardium. However, there were no signs of gastrograffin leakage. The fistu",
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"content": " la between the posterior wall of the transposed <|endoftext|>",
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"content": "A 41-year-old woman presented with abnormal vaginal bl",
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"content": " eeding for 2 months. <|endoftext|>",
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"content": "A 53-year-old man presented with a sudden onset of severe diffuse headache followed by dizziness. The patient had no remarkable medical history, except for hypertension, and had not suffered from any recent head trauma. On clinical examination, there was no focal neurological deficit. The systemic blood pressure was normal. Soon after arrival, the patient showed a confused mental status.\nA noncontrast CT scan of the head revealed a large amount of SAH in the basal cisterns and left sylvian cistern () with a small amount of subdural hemorrhage in the left frontal convexity. On the CT scan, there was also a small hyperdense mass-like lesion seen in the left sphenoid ridge, which showed bony destruction of the left sphenoid ridge with extension into the left anterior middle cranial fossa () and the sphenoid paranasal sinus. This lesion showed mild enhancement and was suspected to be in contact with the left MCA as seen on a contrast-enhanced CT scan (). The possibility of an SAH originating from the ruptured aneurysm was suggested; therefore, cerebral digital subtraction angiography was performed. Cerebral angiography showed no evidence of aneurysms or arteriovenous malformations, but demonstrated a mild focal dilatation at the proximal M2 portion of the left MCA () and a small tumor blush from the left middle meningeal artery. Since the possibility of an aneurysm was eliminated, an SAH originating from the malignant tumor with vascular invasion was suspected. MR imaging revealed an extraaxial mass lesion in the left sphenoid greater wing with slightly high signal intensity on T2-weighted images and enhancement on contrast-enhanced T1-weighted images (). This lesion showed no definite uptake on a PET scan, suggesting a benign or low-grade tumor ().\nA left frontotemporoparietal craniectomy was performed. There was a soft tissue mass lesion adjacent to the left MCA. The mass was tightly adhered to the left MCA, and result",
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"content": " ed in perforation at the MCA bifurcation area (). <|endoftext|>",
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"content": "A 61-year-old postmenopausal woman presented with right outer breast pain, redness and swelling of 3 days duration. Mammogram was essentially normal at that time. Ultrasound of her right breast revealed no masses but increased echogenicity and skin thickening in the outer half of her breast, likely due to inflammation. Clinical impression was that of right mastitis. She was treated with 1 week of oral antibiotics and responded with resolution of her symptoms. A follow-up ultrasound performed 1 month later showed improvement of the inflammatory changes in the right breast.\nThe patient then remained well until she presented 8 months later with another similar episode of right mastitis over the previously affected area. An ultrasound performed this time again showed skin thickening in the right outer breast with underlying inflammatory changes. No discrete nodule or collection was seen. The patient’s symptoms again improved with antibiotics with complete resolution of the redness and swelling of her right breast.\nHowever, the patient returned 6 months later presenting with another similar episode of right breast redness, swelling and pain. Physical examination then revealed right nipple retraction and signs of inflammation over the previous area of interest. Repeat ultrasound (Figure ) showed marked inflammatory changes in the",
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"content": " right breast with skin thickening, suggestive of an inflammatory process. <|endoftext|>",
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"content": "A 6-year-old boy fell from a chair and injured his left elbow. A hanging cast was applied at a local clinic, and he presented to our hospital 2 days after the injury. Upon presentation, he complained of pain in the left humerus, but no neurological findings or impediment to blood flow was found on physical examination. Plain radiographs showed a displaced fracture at the distal humeral diaphysis of the left humerus. The fracture was not reduced and was remarkably unstable (Fig. ). Magnetic resonance imaging showed a vertical fracture line extending into the lateral humeral condylar physis of the distal humerus (Fig. ). Surgical treatment was required because of the severe displacement of the fracture and difficulty maintaining alignment for reduction. Informed consent was obtained from the patient and his parents for surgery and publication of this case.\nWith the patient under general anesthesia, closed reduction of the distal humeral fracture was initially attempted under fluoroscopic control. However, this could not be achieved with anatomic reduction because the fracture was extremely unstable and irreducible. We made an anterior mini-incision on the cubital skin line and removed the brachial muscle, which was preventing reduction in the fracture part. After removal of the brachial muscle, the displacement of the fracture was easily reduced and the alignment could be maintained by thumb compression (Fig. ). Percutaneous intramedullary fixation was performed using 1.5-mm Kirschner wires, inserted from the humeral distal metaphysis (Fig. ). Once the distal humeral di",
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"content": " aphyseal fracture was stabilized using the intramedullary wires, the <|endoftext|>",
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"content": "A 63-year-old African man presented to the University Health Center of Sultan Qaboos University, Muscat, Oman with a six-month history of painless penile swelling. The patient denied any history of genital trauma, urethral discharge, or any other urinary symptom. The patient had no other skin lesions. He was married and had no extra-marital relationships. Examination revealed a 1 × 2 cm firm and non-tender nodule in the ventral part of the penis. The patient was referred to the urology clinic where he had an excisional biopsy of the swelling. Histopathology of the lesion showed epithelioid histiocytes palisading around a nuclear dermis with mucin deposition, which was suggestive of granuloma annulare [].\nOne year later, the patient presented with similar painless skin nodules, but over his right upper limb. These skin nodules had subsequently spread to involve his chest and trunk. He did not report any respiratory symptoms, fever, or joint pain. Family history was unremarkable, particularly for any similar symptoms or malignancies.\nOn examination, the patient was well-built, and he looked comfortable. He had no palpable cervical or axillary lymph nodes. There were multiple 1 × 2 cm, firm and non-tender subcutaneous nodules over the right arm, chest, and trunk. His chest was clear, and his cardiovascular examination was normal.\nLaboratory tests, which included complete blood count, fasting blood glucose, and liver function tests, were all normal. His renal function tests showed features suggestive of an acute kidney injury with high creatinine level and low glomerular filtration rate (GFR). The levels of potassium and bicarbonate were within the normal range. A summary of the results of his laboratory tests is shown in .\nHis chest X-ray revealed a superior mediastinal mass with a bilateral hilar enlargement []. Chest computed tomography showed multiple e",
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"content": " nlarged mediastinal and hilar lymph nodes <|endoftext|>",
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"content": "A 52-year-old woman presented with pain and active function loss in her left shoulder, and was admitted to our hospital in June 2017. Her shoulder problem had started 3 months earlier, and there was no history of trauma or fracture. At first the pain was intermittent and bearable, but then gradually increased. On examination, there were no positive signs except for localized pain. A radiologic examination on 3 April 2017 found no destruction of the shoulder (Fig. ). Pain at the shoulder joint became gradually aggravated, together with the appearance of shoulder joint dysfunction. Two months later, physical examination revealed mild swelling of the shoulder,",
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"content": " and markedly restricted shoulder and elbow motion. <|endoftext|>",
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"content": "A 66-year-old woman presented to the surgical outpatient clinic with a 2-month history of bright red rectal bleeding and intermittent diarrhoea. No history of weight loss, foreign travel or dietary change was reported. She suffered from hypertension but had no other comorbidities. She took amlodipine daily and did not drink alcohol or smoke. No significant family history was elicited.\nPhysical examination was unremarkable, and routine blood tests were normal. A flexible sigmoidosopy however demonstrated mild–moderate inflammation from the rectum to the rectosigmoid junction, and biopsies taken showed features consistent with moderately active UC (see ). The patient was subsequently started on oral and topical 5-aminosalicylic acids (5-ASAs), but in the following months, her UC worsened and her liver function tests began to rise. Within a year after first presentation, oral steroid therapy in combination with 5-ASAs failed to control the patient's UC, and she was admitted urgently to hospital and referred to the gastroenterology department. However, despite intravenous steroids, antibiotics and ciclosporin rescue therapy, the patient's condition worsened. Her care was transferred back to the surgical team, and a subtotal colectomy with loop ileostomy was performed.\nThe subtotal colectomy was successful, and no complications of the surgery were experienced. However, shortly after discharge from hospital, the patient began to experience right upper quadrant pain and her liver function tests remained persistently raised. At this point, the surgeons referred the patient to a hepatologist for an opinion. PSC was suspected, and a full serological work up for liver disease was performed. This demonstrated",
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"content": " antiproteinase 3 antibody (cANCA) positivity only, and the rest of <|endoftext|>",
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"content": "An eighteen years old, unmarried, Saudi female, underwent bariatric surgery. Three months after the procedure, she complained that she had experienced weakness in both lower limbs for a period of 3 weeks. This was associated with a burning sensation, which had started on the soles of her feet and progressively over a period of 2 weeks had increased until it reached her thighs, making it difficult for her to stand and walk without support. Although this weakness did not affect her upper extremities, she eventually became bed bound and dependent on her family members for her daily needs. She also reported that she had suffered from dizziness and intermittent mild blurring of vision. Initially, she also had suffered from vomiting, which had improved with medication. She did not report a history of headaches, double vision, confusion, seizures, difficulty in swallowing or speaking, sphincter dysfu",
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"content": " nction, or fever. <|endoftext|>",
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"content": "A giant renal angiomyolipoma (AML) measuring 18 × 13.2 × 22.4 cm was found in the left kidney of this 43-year-old female (with no evidence of tuberous sclerosis",
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"content": " [TS]). <|endoftext|>",
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"content": "A 75-year-old male patient was sent to our hospital suffering from left hip pain sustainedly after an accidental fall. Radiographic imaging revealed that this patient was affected by Crowe type IV DDH combined with an Evans type III intertrochanteric fracture of left femur (Fig. a). The patient reported a history of left hip trauma at the age of 10, at which time he did not accept proper treatment. The resultant left hip deformities had since caused the patient to walk with a limp. Prior to his fall, the patient was able to bear weight and work with moderate left hip pain. Physical examination revealed the left leg to be 4 cm shorter than the right leg, with local tenderness being detected in the left hip. In addition, p",
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"content": " ercussive pain in the left femur in the <|endoftext|>",
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"content": "A 55-year-old man with no known past medical history presented to the hospital with a four-week history of swelling and pain in the right side of the neck. The patient experienced dysphagia to solids as well as subjective fever accompanied by chills. He denied any trauma to the neck but did have 15 lb. weight loss. He did not have any recent dental pain or dental work. He had not experienced abdominal pain or diarrhea over the preceding month but did admit to polydipsia and polyuria. There was no history of raw milk consumption or undercooked meat exposure. The patient was born in Mexico and had been living in New York for three years, without any other travel history. He denied history of tuberculosis exposure or intravenous drug use and had never been tested for HIV. He had no pets in New York or in Mexico. On presentation the patient was mildly tachycardic and febrile (38.5°C). Physical exam revealed a tender, erythematous, nonfluctuant 6 × 7 cm ma",
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"content": " ss in the right neck extending from the mandible of <|endoftext|>",
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"content": "The patient is a 40-year-old man who presented to the Mycetoma Research Centre (MRC) in Khartoum, Sudan with a painful left shoulder mass lesion and multiple sinuses discharging purulent discharge and black grains. He experienced increasing pain and loss of shoulder function over 3–4 months, alongside nausea, vomiting, and anorexia.\nFourteen years earlier, the patient recalled a laceration to the left shoulder during a traditional sword dance. This penetrating trauma may well relate to the current infection. The clinical course of the laceration infection lasted six years. He presented to his local rural medical centre six times, undergoing two surgical incisions and curettage procedures with subsequent physiotherapy. These achieved good functional restoration, but a definitive diagnosis was not achieved. The swelling recurred sometime later. At his fifth local consultation, four months before presenting to the MRC, a differential diagnosis of mycetoma was raised and he was started on oral itraconazole. Two months later he returned for his sixth consultation at his local health centre when it was noted the swelling had increased in size, accompanied with pain, discharging sinuses, and the systemic features noted above. He was admitted to the local health facility for 11 days and treated with intravenous benzyl penicillin, cefuroxime, and analgesia. Blood test at this time showed raised erythrocyte sedimentation rate (ESR) (110/hour). No surgical biopsy or cytology smears ",
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"content": " were taken from the lesion, but, following discharge, he <|endoftext|>",
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"content": "An 83-year-old Hispanic male with an extensive past medical history including chronic hepatitis C, coccidioidomycosis, ocular myasthenia gravis, and interstitial lung disease presented to the Emergency Department (ED) with a complaint of chronic cough, shortness of breath, upper extremities weakness with diplopia, and dysphagia. The ",
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"content": " patient reported a daily cough with sputum production since Thanksgiving <|endoftext|>",
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"content": "A 34-year-old systemically healthy Malay woman was referred to the Periodontics Specialist Clinic of the Kulliyyah of Dentistry, International Islamic University Malaysia, with a chief complaint of bleeding gums and mobility of her upper anterior teeth. Complete medical and dental histories were taken, and a full periodontal chart was recorded, including all the clinical periodontal parameters, plaque scores and bleeding on probing (BOP), probing pocket depth (PPD), clinical attachment loss (CAL), recession, mobility, and furcation involvement. The chart revealed grade II mobility of the UCI and pus discharge with deep probing depths and severe CAL >6mm. The three-dimensional picture in Fig. shows the circumferential bone resorption surrounding the UCI. The rapid rate of bone destruction affected the sites of the first and second molars, resulting in furcation involvement and mobility ranging from grade I to grade II with recorded PD and CAL greater than 6mm as well. The radiographic interpretation showed an angular bone defect mesial and/or distal to the first molars (Fig. ). Because the patient was systemically healthy except for the presence of periodontitis, and based on the patient’s history, clinical periodontal records, and radiographic findings, she was diagnosed with localized aggressive periodontitis []. A combination of oral metronidazole 400mg and amoxicillin 500mg were prescribed for 7 days as an adjunct to scaling and root planing (SRP). Six weeks after the NPT, the affected sites were reevaluated. The results revealed slight reductions in the patient’s BOP, PD, and CAL. However, the range of residual bleeding pocket depths was from 5mm to 6mm with no obvious clinical attachment gain. Therefore, the decision was made to provide regenerative therapy, and a surgical treatment was scheduled for the patient in spite of the quest",
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"content": " ionable prognosis that had been assigned at baseline. <|endoftext|>",
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"content": "A 60-year-old male who had a history of liver cirrhosis was referred for evaluation of a pain, swelling, and erythematous changes of the anterolateral aspect of his left leg. His symptoms started a month ago without any specific trauma. He had a history of open reduction and internal fixation performed for a tibial plateau fracture that occurred when his left knee was pinned under a tree 18 years ago. He had sciatic nerve injury at the time of the fracture. He had an open reduction and internal fixation as well as a stent insertion in the femoral artery 8 years after the initial trauma due to a distal femur fracture and femoral artery rupture. At that time, a widespread radiopaque mass was observed on plain radiographs of left leg, and obstruction of popliteal artery with abundant collateral circulation was observed on angiography. The patient had no difficulty with his daily life functions until the aforementioned symptoms appeared, except for limited motion in the ankle and toes and sensory reduction in his foot owing to the sciatic nerve injury.\nAfter admission, the patient maintained with a long leg splint. Two weeks after the admission, the erythematous changes in the left leg localized to the anterior aspect in the middle of the leg and formed a fluid-filled, erythematous mass. A draining sinus had developed on the erythematous mass spontaneously and a thick fluid with a chalk-like material was discharged through the shiny skin via the sinus. The range of motion of the knee was 0 degrees to 100 degrees of flexion; ankle dorsiflexion was 0 degrees, ankle plantar flexion was 5 degrees, and all of the toes had clawing deformity. As for the motor strength of the ankle, the dorsiflexion was grade 0 and plantar flexion was grade 3. He had no sensation in the first web space and on the medial aspect of the foot, and had sensory reduction in the lateral, dorsal, and plantar aspects of the foot, in order of decre",
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"content": " asing sensation. <|endoftext|>",
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"content": "A 24-year-old female presented to the Emergency Department of a tertiary hospital in Brisbane with a 48-hour history of diarrhoea and vomiting. Her medical history included primary carnitine deficiency, a rare inherited metabolic disorder that causes cardiomyopathy, which was diagnosed as asymptomatic during her infancy following the death of her infant brother from cardiomyopathy related to the condition. Her diagnosis was established by impaired cultured fibroblast carnitine uptake. Her genotype is unknown. She was prescribed oral carnitine replacement, 400 mg TDS, but had been not compliant with this therapy for the preceding three months. She reported no history suggestive of cardiac failure or arrhythmia. Cardiovascular and respiratory examination was normal. Chest X-ray revealed an increased cardiothoracic ratio. Electrocardiogram demonstrated enlarged peaked T waves and a short QT interval (). Her serum total carnitine level was 4 μmol/l (21–70). Intravenous carnitine replacement was commenced, and she was admitted for telemetry and cardiac evaluation. Her gastrointestinal symptoms resolved early in her admission and did not reoccur.\nEchocardiography performed within 24 hours of commencing carnitine replacement revealed a dilated cardiomyopathy. The left ventricle was severely dilated with a left ventricular end diastolic volume ",
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"content": " index of 104 ml/m2 (normal < <|endoftext|>",
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"content": "A 65-year-old female patient with previous abdominal surgery in a regional hospital in Bahir Dar 6 months prior to this presentation presented with diffuse abdominal pain, weakness, and occasional vomiting of ingested material of 6 months duration. There was no history of abnormal uterine bleeding, oral contraceptive use, or gynecologic operation. The patient gave written informed consent to publish this case report. The biopsy result of her surgery in Bahir Dar was suggestive of gastrointestinal stromal tumor. On examination, she looked chronically sick, was emaciated and slightly pale and had a long midline abdominal scar; there was also mild tenderness all over the abdomen on deep palpation. Investigation revealed a hemoglobin value of 9.3 g/dL and a WBC count of 6,900/μL. She had O +ve blood group and had normal liver and renal function as well as a normal chest X-ray.\nUltrasound showed enumerable hypoechoic intra- abdominal masses of different sizes () and a large hypoechoic liver mass measuring 7.5×4.7 cm2 in the right lobe (). Laparotomy later revealed innumerable globular masses arising from the mesentery and walls of whole small bowel, some pedunculated but most sessile ( and ). In addition, there was a large liver mass of approximately 8×10 cm in the right lobe with normal pelvis. Multiple biopsies were taken from the mesenteric and superficial small intestinal masses but not from the liver mass for fear of bleeding and abdomen closure. Biopsy specimens were sent to two centers, and both reported a similar finding of highly cellular interlacing bundles of proliferating smooth muscle cells not associated with nuclear atypia or mitotic figures, and the",
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"content": " re was no necrosis seen. <|endoftext|>",
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"content": "A 48-year-old Caucasian man with past medical history of asthma, diverticulitis, benign prostatic hyperplasia, presbyopia, and obesity presented with a tender palpable left forearm mass. The pain started five years after the patient sustained a deep knife wound in this area that required stitches. Initially, without significant discomfort, the mass progressively grew for years. The pain worsened significantly in the last eight months prior to presentation as he began experiencing dysesthesias that radiated distally to his thumb, index, and middle fingers when the mass was lightly touched. The pain had become so bothersome to the patient that even the wind blowing across his forearm caused extreme discomfort. It affected his livelihood as a truck driver and was deterring him from playing golf.\nPlain radiograph revealed a 1.6 cm ovoid density within the lateral soft tissues of the left forearm (Figure ). Subsequently, a MRI of the left forearm was taken, which showed a 1.6 x 1.3 x 1.8 cm subcutaneous mass with low T1-weighted signal intensity that avidly enhanced with contrast and high-intensity signal on T2-weighted imaging (Figure ). The mass was closely associated with the neurovascular bundle following the course of the superficial branch of the radial nerve (Figure ). This led to the initial conclusion of the mass resembling an intrinsic nerve tumor such as schwannoma, neurofibroma, or a traumatic neuroma.\nOn physical examination, light touch of the mass elicited significant discomfort and dysesthesias in the distribution of superficial branch of radial nerve, but sensation t",
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"content": " o both light touch and pinprick <|endoftext|>",
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"content": "A 21-year-old man presented to our movement disorders clinic with a 12-year history of attacks of involuntary movements of both upper limbs and upper trunk. These attacks are often triggered by sudden movements such as standing up quickly or running on the spot. The patient was conscious of experiencing a certain “feeling” before the onset of an attack. The patient was able to prevent these attacks by standing up slowly. He once had a febrile seizure when he was 2 months old and was treated in Children Hospital No. 1 in Ho Chi Minh City with an unclear diagnosis and treatment. He had no family history of similar conditions, epilepsy, seizure, or other movement disorders. These attacks were increased in frequency to >20 times a day, rendering him from continuing his education 3 years after symptom onset. His parents thought the symptoms were related to psychological disorders, so the patient did not receive proper medical care. When he was 21 years old, he was referred to a local psychiatric hospital in Ho Chi Minh City. A brain MRI and electroencephalogram were done, but no abnormal sign was found. He was diagnosed with “conversion disorder.” He was prescribed amisulpride 400 mg ½ tablet, BID; trihexyphenidyl 2 mg 1 tablet, BID; and valproate magnesium 200 mg 1 tablet, BID, for 2 months, but there was not any amelioration. He then withdrew medications for 6 months, and the symptoms unchanged.\nFinally, he came to our Parkinson's disease and Movement disorders clinic at Ngu",
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"content": " yen Tri Phuong Hospital. <|endoftext|>",
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"content": "A 43-year-old Caucasian man was referred to the Department of Internal Medicine at the University Teaching Hospital in Cagliari. His clinical manifestations started in 2002 with a sudden onset of neurological symptoms. Magnetic resonance imaging (MRI) of lesions was consistent with a diagnosis of multiple sclerosis. Our patient, employed as a prison officer, was not deemed fit for work. In 2003, he was admitted to a small community hospital where he was also diagnosed with hypertension, polycythemia and intermittent claudication. Finally, in 2006, he was referred to the Multiple Sclerosis Centre at Cagliari University where a vascular origin was postulated for his neurological symptoms. Tests carried out on fibrocalcific atherosclerotic lesions accounted for the concomitant presence of systemic hypertension, polycythemia, brain injury and peripheral arterial occlusion. His electrocardiogram (ECG) findings were normal, although due to a compromised limb function, an exercise ECG could not be performed. Ethical reasons also dissuaded us from performing a coronary angiograph.\nHis family history for cardiovascular events was negative. A brain MRI revealed mild cortical atrophy with bilateral lacunar ischemic lesions and gliosis in his cerebral white matter, mainly in the semi-oval center and the corona radiata (Figure ). The presence of extensive arterial damage with bilateral atherosclerotic lesions was revealed using color Doppler ultrasound. Abdominal computed tomography (CT) angiography of his aor",
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"content": " ta and lower limbs showed widespread fibrocalcific <|endoftext|>",
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"content": "We discuss the case of H., a four-year-old African-American boy, who was referred to the neuropediatrics department of a university hospital by the genetics department. He was admitted with a WS diagnosis through microsomal analysis by microarray. His mother reported developmental delay in the child, along with gait and language difficulties. H. had been born by cesarean delivery due to alterations detected on ultrasound and restricted growth. Some interesting factors observed during the first appointment were as follows: the infant was just starting to learn how to speak, and was showing an evident delay in speech development; he did not have sphincter control and was highly irritable. Regarding social interactions, he was able to make conversations with other people, but very poorly. He would also often hit his head on the floor, and slap his own face when annoyed. H. could not eat by himself either, as he had difficulty in chewing. H. had been born",
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"content": " when his mother was 34 years old, and she already <|endoftext|>",
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[
{
"content": "This case describes a 23-year-old male who was struck by a motor vehicle. Upon arrival at our hospital, the patient had a GCS of 8. FAST exam, chest radiograph, and computed topography (CT) of the head and cervical spine were obtained and were negative.\nExam of the lower extremities revealed abrasions over the left knee and tenderness over the lateral joint line with an effusion. The right knee was diffusely tender to palpation without effusion. The patient had palpable pulses in both feet with well-perfused extremities. Ankle brachial indices were performed and found to be >0.9. He demonstrated guarding and pain with the attempted Lachman maneuver of the left knee and slight opening of the left knee joint with varus stress. Radiographs were obtained and revealed a left knee Segond fracture ().\nMagnetic resonance imaging (MRI) of both knees was performed to evaluate for ligamentous injury. Left knee imaging demonstrated the Segond fracture along with a grade III lateral collateral ligament (LCL) tear with retraction (), a grade II tear of the popliteus tendon and anterior cruciate ligament (ACL) (), and a grade I medial collateral ligament (MCL) injury (), as well as partial thickness tears of the biceps femoris and vastus medialis. Right knee imaging revealed a grade III tear of the ACL and MCL (), grade II tears of the posterior cruciate ligament (PCL) (), LCL, and popliteus tendon, and a medial meniscus tear. The patient was placed in bilateral hinged braces with the left knee unlocked and the right knee in locked extension to aid with transfers from a bed to a wheelchair. The patient was also given a left foot drop boot for a foot drop discovered during a secondary exam. On hospital day three, the patient was discharged home.\nNine days after the accident, the patient presented to the clinic. He noted that the left-sided foot drop",
"role": "user"
},
{
"content": " was improving. <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "A 48-year-old female came to our observation due to a limitation in mouth opening range. She also reported crepitus sounds at the left TMJ as well as pain, exacerba",
"role": "user"
},
{
"content": " ted by function (e. <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "A 17-year-old female patient was diagnosed and treated in the Department of Oncological Gynecology and Gynecology due to a suspected recurrence of JGCT. The patient began menstruating at the age of 12. At the age of 15, menses became irregular and, in addition, hormonal disorders and dermatological problems appeared. The following diagnoses were made after a number of diagnostic tests: hypothyroidism, insulin resistance, psoriasis, and hirsutism. The patient received appropriate treatment and was under constant care of specialist clinics. Before 2018, she did not undergo surgery. In her family, there were no malignancies. In 2018, the patient underwent laparoscopic enucleation of the left ovarian tumor. Following the histopathological result, FIGO (International Federation of Gynecology and Obstetrics) IA folliculoma was diagnosed. The patient was informed of the need to undergo regular physical examination, imaging, and laboratory tests every 3–4 months to evaluate the efficacy of surgical treatment and early detection of a potential relapse. The first two follow-up visits showed no cause for concern. At 9 months, the ultrasound examination showed a tumor in the left ovary, 7 cm in diameter, suggesting a recurrence of folliculoma. Magnetic resonance imaging confirmed the initial diagnosis (Fig. ). The patient did not suffer any pain, the laboratory test results were within the normal range, and there were no hormonal fluctuations, except a high level of testosterone and insulin (Table ). The patient was qualified for surgery. Potential therapeutic options were discussed with her and her parents, paying attention to the patient's young age and the need for fertility preservation. The patient did not agre",
"role": "user"
},
{
"content": " e to the recommended unilateral oophorectomy and staging procedures. <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "A 14-year-old female patient had come to the Department of Orthodontics, with the chief complaint of forwardly placed upper front teeth. Her medical history was found to be noncontributory.\nOn extraoral examination, facial asymmetry was evident for which patient was unaware. There was no history of trauma. The patient did not have any difficulty in opening of mouth. Inspection showed elongation of left side lower half of face as compared to the right side. The left side of the face appeared flattened as the prominence of the chin appeared shifted to the right side [].\nOn intraoral examination, her molar relationship was found to be Angles Class II on right side and end on the relationship on the left side. The lower midline was shifted 3 mm to the right side with respect to maxillary midline [].\nRadiographic investigations were also carried out. Panoramic view of girl revealed symmetrical condylar enlargement of the left side in comparison to the right side and condylar neck along with the elongation of the left side of ramus [].\nPA cephalogram of the girl showed a shift of dental midlines due to the asymmetry of the mandible [].\nHer mother who was 44 years old had accompanied her and asymmetry in her face was also noticed. She was unaware of it and gave consent to be examined. On examination, she did not have any difficulty in opening her mouth. The chin was deviated to the right side as left side of her face was elongated. The left side of face appeared flattened [].\nIntraorally, her oral mucosa was normal with permanent dentition and a total of 24 teeth. Her oral hygiene was poor and no previous history of trauma. Medical and family history was noncontributory. There were root stumps and carious teeth present. Maxillary right first molar had already been extracted. Clinicall",
"role": "user"
},
{
"content": " y, she showed a lower midline shift to the right <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "A 34-year-old Polynesian woman, presented to the Gynaecology services with intermittent vaginal bleeding and a raised total serum hCG of 96 IU/L (Abbott Architect, Abbott Laboratories. Reference Range < 5 IU/L) which was confirmed on weekly serial hCG levels over the preceding month. She did not have a significant past medical history or family history and was not on regular medications. Her reproductive history included four live births (the most recent was a term pregn",
"role": "user"
},
{
"content": " ancy six months prior to presentation), a spontaneous miscarriage <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "A 5-year-old boy presented at the emergency department of our hospital with fever and dyspnea. He had no significant medical history except for allergic rhinitis. General examination revealed respiratory distress with cyanosis of the lips, and physical examination revealed prominent intercostal retractions and expiratory wheezing. A chest X-ray revealed bilateral infiltration of the proximal bronchus (figure not shown). Blood examinations indicated a mild inflammatory pattern, and urine test revealed no significant abnormalities. A rapid antigen test of nasopharyngeal mucous specimen showed positive for influenza A. Only Haemophilus influenzae was detected in the nasal culture, and the mycoplasmal antibody titer was not elevated. He was admitted on the same day, and we immediately started treatment with intravenous hydrocortisone, cefoti",
"role": "user"
},
{
"content": " am, and peramivir (an intravenous antiviral agent available in Japan). <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "A 65-year-old female presented to our outpatient department (OPD) with complaints of recurrent swelling over the lateral aspect of the left foot associated with pain and difficulty in walking for three months. The patient had developed soft-tissue swelling over the lateral aspect of the left foot three years back, which had been treated at an outside facility with an excisional biopsy of the swelling, according to the medical records. The histopathological examination (HPE) had revealed an EHE of the left calcaneum with positivity for Fli-1, CD31, and Vimentin. The patient had not received any adjuvant chemotherapy or radiotherapy after this procedure. A year later, she again developed swelling over the same area with ulceration of the overlying skin, for which she presented to our OPD. The swelling was insidious in ons",
"role": "user"
},
{
"content": " et, gradually progressive in size and associated with pain. <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "A 70-year-old male presented with an eight month history of looser stools. His medical history included a right lung lobectomy for tuberculosis aged 20, chronic obstructive airways disease and ischaemic heart disease. He was a long-term smoker.\nGeneral examination showed him to be well with no lymphadenopathy. No mass was palpable on digital rectal examination. Full blood count, urea and electrolytes and liver function tests were all within normal limits.\nFlexible sigmoidoscopy and biopsy identified a rectal adenocarcinoma at 8 cm from the an",
"role": "user"
},
{
"content": " al margin. <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "This is a single case report of a 3-year-old girl child with 20% total body surface area with scald burns over trunk and right thigh, managed at the tertiary burn care center ",
"role": "user"
},
{
"content": " of our institute. <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "A 16-year-old boy presented at the outpatient Department of Ophthalmology with chief complaints of continuous irritation of the right eye along with infrequent watering since 5 months. There was no history of loss of vision. Apparently, the patient also noted a small swelling over the right lower eyelid which was gradually increasing in size thereby causing a cosmetic problem as well. Patient's symptoms of irritation and watering were also increasing with the increment of the size of the swelling, but there was no history of pruritus. There was no familial history of such lesion. The patient denied any comorbidity and did not take any re",
"role": "user"
},
{
"content": " gular medication for any other disease. <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "An 87-year-old Caucasian man presented to our institution with chest and epigastric pain radiating to his back. Computed tomographic scans were performed urgently, and these showed a large Crawford type I thoracoabdominal aortic aneurysm (Figure ). The aneurysm measured 17 cm in length and was 5 cm to 6 cm distal from the left subclavian artery and 2 cm to 3 cm proximal to the celiac axis. The maximum anteroposterior diameter of t",
"role": "user"
},
{
"content": " he aneurysm was 13 cm above the diaphragm. <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "A 30-year-old female patient presented with complaints of sudden onset painful and rapidly progressive diminution of vision in the left eye of 2 days duration. She gave a history of being administered intravenous drugs multiple times for her episodes of headache over the past 6 months. There was no history of trauma or ocular surgery. There was no history of any systemic illnesses.\nOn examination, best corrected visual acuity (BCVA) was 6/6 in the right eye and finger counting close to face with accurate projection of rays in the left eye. Intraocular pressure was 13 mmHg in the right eye and 10 mmHg in the left eye. On slit lamp biomicroscopy, there was mild ciliary congestion, anterior chamber cells of 4+ with a hypopyon of approximately 1 mm in the left eye. On indirect ophthalmoscopy, there was evidence of 3–4+ vitritis. A solitary elevated yellowish lesion could be hazily seen in the superotemporal quadrant giving suspicion of an abscess. Combined vector ultrasound B-scan confirmed the presence of a subretinal abscess associated with vitreous exudates. There was no evidence of retinal detachment or choroidal detachment.\nOn systemic examination she had evidence of cellulitis of the left lower limb. Blood cultures (aerobic and anaerobic bacterial and fungal) were sent before initiating intravenous antibiotics. Results of all other relevant investigations were normal.\nBased on the clinical picture, a diagnosis of endogenous endophthalmitis with subretinal abscess was made. She was started on intravenous Vancomycin (40 mg/kg/day) and Ceftriaxone (100 mg/kg/day). Pars plana vitreous biopsy was performed along with injection of intravitreal antibiotics (Vancomycin 1 mg/0.1 ml and Ceftazidime 2.25 mg/0.1 ml). Gram stain and culture of the vitreous specimen did not reveal any organism. Blood culture and urine culture al",
"role": "user"
},
{
"content": " so failed to grow any organism. <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "A 50-year-old female patient presented to us with tingling sensation over both lower limbs which affected the right side more than the left side for the last 6 weeks. She then developed weakness of both lower limbs which initially affected the right side manifesting as heaviness in legs followed by stiffness and difficulty in walking. Weakness was insidious in onset but rapidly progressed to involve both lower limbs that patient was unable to stand without support in the next 4 weeks. When she came to us, both her lower limbs were severely spastic. Power in both her lower limbs was MRC 1/5. Tone and power in both upper limbs were unaffected. Reflexes in both lower limbs were exaggerated. Bilateral plantars were extensor. She had no sensory deficits. The patient underwent magnetic resonance imaging (MRI) of the cervicodorsal spine [] which revealed an heterogeneously enhancing intraspinal tumor at D1–D2 level on the right side causing cord compression and pushing it to the opposite side. The tumor extended into the right D1–D2 foramen with extension into paravertebral area. Noncontrast computed tomography cervical spine showed mild degenerative changes with anterior osteophyte formation and right facet joint arthropathy from C4 to C7 level. The right side D1–D2 neural foramina was wider and the D1 pedicle thinned out as compared to the left side []. With a possible diagnosis of peripheral nerve sheath tumor with cord compression, the patient underwent D1-D2 laminectomy using posterior midline incision in the prone position. A large reddish pink color extra dural tumor extending from C7 to D",
"role": "user"
},
{
"content": " 2 level was seen on the right anterolateral side <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "A 51 year-old woman with a past medical history of well controlled asthma, allergic rhinitis and atopic dermatitis was referred to our university clinic complaining of chronic urticaria for the previous three years. She experienced almost daily episodes of hives that would last less than a day and were intensely pruritic. Prior to presentation in our clinic, she was treated by several physicians with various combinations of high dose first and second generation antihistamines without success. Montelukast offered no benefit when added to treatment with antihistamines. However, relief was obtainable with oral prednisone (20 mg/day) or cyclosporine (200 mg daily in divided doses). A biopsy was obtained which confirmed the diagnosis of true urticaria and ruled out urticarial vasculitis. During the course of her work up, a number of laboratory tests were ordered and were unrevealing as to the potential etiology of her hives (Table ). She noted no association of symptoms with food or medications. Despite frequent monitoring, she was fearful of the potential toxic effects from cyclosporine after she experienced a transient decrease in renal function of unknown significance. Additionally, she was intolerant of prednisone when used at times in place of cyclosporine due weight gain and psychosis. In an effort to find a more tolerable and effective alternative, treatment was initiated with omalizumab 300 mg every two weeks. This dose was chosen based upon the severity of her symptoms and previous successful outcomes []. After the first treatment with omalizumab, the patient noted significant improvement. Over the course of the subsequent 2 weeks, she was able to wean cyclosporine down to 25 mg daily without experiencing an urticarial flare. This was the lowest tolerable dose required to prevent flares until the eigh",
"role": "user"
},
{
"content": " th treatment visit at which <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "A 55-year-old female was referred to our institution with a diagnosis of juxtarenal abdominal aortic aneurysm. She had complaints of severe abdominal pain over the pa",
"role": "user"
},
{
"content": " st 10 days, which was radiating to the back and <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "A 61-year-old woman, gravida 3 para 3, last menstruation at 54 years of age, reported to her gynecologist complaining about irregular post-menopausal",
"role": "user"
},
{
"content": " hemorrhaging and a mass emerging from the external cervical <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "A dyspneic 69-year-old male was referred for further management to our tertiary referral hospital with suspicion of pericardial effusion and cardiac tamponade. He suffered typical chest pain, diaphoresis, and an anterior myocardial infarction 3 days before admission to our hospital and was treated with streptokinase in a general medical center. He also underwent dopamine and dobutamine therapy in that center because of a significant reduction in his blood pressure.\nOn admission, he had a pulse rate of 105 bpm, a blood pressure of 80/65 mmHg, and a respiratory rate of 25 (O2 saturation = 92%). On physical examination, he had muffled heart sounds and a fine crackle in the lower two-thirds of both lungs. His jugular venous pressure was higher than normal, and his electrocardiography showed sinus rhythm with significant Q waves in V1 through V6 precordial leads.\nInitial transthoracic echocardiography showed a severe abnormal left ventricular ejection fraction (LVEF = 20%) with a massive pericardial effusion with hemodynamic effect (right ventricular outflow tract collapse). The results were highly suggestive for rupture of the apical septal myocardium with clot formation.\nThe operation was performed through a standard median sternotomy. The proximal part of pericardium was partially opened, and a controlled amount of blood was removed gradually, which immediately improved his hemodynamic indices. Standard cardiopulmonary bypass (CPB) was performed with mild hypothermia (32°C) and standard cardioplegic myocardial preservation. The heart was arrested, and the pericardium was opened completely. Thereafter, the remaining blood was drained. A large myocardial infarction in the apex was seen, and the sub-epicardial hematoma extended to the lateral side of left and rig",
"role": "user"
},
{
"content": " ht ventricular free wall. <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "A 54-year-old woman (gravida 0, para 0) was transferred to our department with an extensively distended abdominal wall and leg pain. Regular menstruation started at age 14, and she experienced menopause at age 48. She had no ",
"role": "user"
},
{
"content": " history of regular hospitalizations. <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "A 58-year-old male with severe lung disease due to end-stage chronic obstructive pulmonary disease (COPD) requiring tracheal intubation and ventilation underwent CTI ablation for a new diagnosis of AFL causing hemodynamic instability. In the electrophysiology lab his ECG showed AFL with 4:1 conduction. AFL cycle length was 180 ms, preventing entrainment maneuver. Under direct fluoroscopy guidance, a Bard DECA catheter was advanced to the coronary sinus. Subsequently, an EPT Blazer II 8 mm ablation catheter was advanced to the right atrium and positioned in the CTI area at 6 o’clock position from the left anterior oblique view where ablation was performed at a power of 35 W and a temperature of 45 °C. After initial series of RFAs guided by temperature and impedance, the tachycardia cycle length slowed down to 190 ms. Therefore, entrainment was then attempted with pacing cycle length of 180 ms at the CTI area from 6 - 7 o’clock positions. However, the atrium was not captured. Further RFAs were performed along the CTI employing maximum power up to 100 W and maximum temperature of 60 °C for a maximum of 60 s. Ablation was performed across the CTI between 6 and 8 o’clock positions from the left anterior oblique view without a change in the cycle length. Therefore, coronary sinus catheter was then pulled back to be positioned at the lateral right atrial wall. The atrial activation sequence showed a pattern consistent with typical AFL. Then the coronary sinus catheter was repositioned inside the coronary sinus and entrainment was successful from the proximal coronary sinus, with post pacing interval minus tachycardia cycle length of < 10 - 15 ms. These findings were very supportive again of typical isthmus dependent AFL. Therefore, ablation was performed medially, and just posterior and anterior to coronary sinus os resulting in successful termination of AFL and resumption of si",
"role": "user"
},
{
"content": " nus rhythm. <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "A 54-year-old diabetic male presented to our outpatient facility with a history of a calcaneal osteomyelitis after a failed calcaneal open reduction internal fixation and a large post-traumatic septic defect of the Achilles tendon area. His past medical history was only significant for type 2 diabetes mellitus controlled by his oral hypoglycemics. The patient had sustained the injury and had an urgent surgical intervention 4 weeks prior to his initial visit in our facility. Pedal radiographs and wound cultures were positive for septic necrosis of the wound and also for growth of Enterococcus and Stenotrophomonas species. The patient was t",
"role": "user"
},
{
"content": " hen admitted for initial surgical debridement and further <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "A 53-year-old woman presented with severe left retro-orbital pain and diplopia for 1 month []. Neurological examination performed on admission in a local hospital revealed left abducens nerve palsy. A magnetic resonance image (MRI) revealed an enlargement of the bilateral CS, i",
"role": "user"
},
{
"content": " n which the left side was dominant []. <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "A 72-year old female patient presented to us with shortness of breath for the last 2 months. There was no history of fever, cough, chest pain, haemoptysis, abdominal pain, vomiting or bleeding per vaginum. There was no lymphadenopathy, clubbing, or pedal edema, but pallor was present. Air entry was decreased bilaterally in the inframammary and infrascapular regions. The cardiovascular system and gastrointestinal system were normal.\nThe laboratory value for hemoglobin (Hb) was 8.0 g/dL. The complete blood cell count (CBC), blood sugar, renal function test and liver function test were all found to be within normal ranges. A posterior to anterior (PA) view chest X-ray () was done which showed homogenous opacity in the bilateral l",
"role": "user"
},
{
"content": " ower lung field along with blunting of both costophrenic <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "A 34-year-old gravida 2 para 1 at 25 weeks gestation was transferred to our institution from an outside hospital. She complained of a two-week history of progressively worsening orthopnea and shortness of breath that left her unable to perform daily activities. An initial transthoracic echocardiogram obtained at the referring hospital had demonstrated a depressed ejection fraction (35%) as well as mild pulmonary hypertension. The patient was transferred to our institution for further evaluation and management.\nHer past medical history was significant for chronic hypertension, class F diabetes mellitus, super morbid obesity with a BMI of 53, and chronic kidney disease. Two years before, she underwent an emergent cesarean delivery at 35 weeks gestation due to preeclampsia with severe features and nonreassuring fetal status. The patient had no previous history of congenital, ischemic, or valvular heart disease. She had no family history of heart disease and never had an echocardiogram before. On admission she required 2 L/min of oxygen per nasal cannula to maintain an oxygen saturation of 95%. The remaining vital signs were within normal limits. Notable findings on the physical exam were presence of S3 and S4 heart sounds, positive jugular venous distention, bilateral crackles on auscultation, and 2+ pitting edema of the lower extremities. A baseline electrocardiogram revealed normal sinus rhythm. Chest x-ray demonstrated pulmonary interstitial edema and bilateral pleural effusions. A transthoracic echocardiogram demonstrated a moderately dilated left ventricle, eccentric left ventricular hypertrophy, and a severely",
"role": "user"
},
{
"content": " reduced left ventricular systolic function with an ejection <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "The patient is a 59-year-old, right-handed Caucasian woman who presented with progressive headache and a",
"role": "user"
},
{
"content": " n abrupt onset of alexia. <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "The patient is an 18-year-old boy not known to have any medical illness previously, who was referred to the outpatient department from another hospital after 3 months history of seizures. Seizures started with blurring of vision and proceed to right sided head deviation and tonic posturing of the right upper limp which progress to generalized tonic-clonic seizures. The episodes are followed by loss of consciousness and postictal suboccipital and frontal tension headache. There was ",
"role": "user"
},
{
"content": " no history of fever, loss of <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "A 4-year-old girl was admitted with a 3-year history of a cardiac murmur, and the admission weight was 17 kg. A 3/6 degree of systolic murmur at the third left intercostal space was detected by physical examination, and a perimembranous VSD of 6 mm was revealed by echocardiogram. The girl underwent VSD closure with inferior partial median sternotomy under cardiopulmonary bypass (CPB) at day 4 of hospitalization, and the VSD was closed with three interrupted horizontal mattress sutures. The operation was successful, and she was discharged at postoperative day 10.\nShe was readmitted at 20 days after the first surgery due to a high fever of 40°C at postoperative day 18 with no obvious causative factors and without characteristics of coughing, wheezing, retching, vomiting, or cardiac murmur. The girl showed a slight poor physical development and with no family history of genetic diseases and dysmorphism. She had received antibiotic therapy for 1 day before readmission at the local hospital. Laboratory examination showed that the white blood cell (WBC) count was 5.94 × 109/L, and the percentage of neutrophils was 81.8%. Blood culture showed positive for Staphylococcus aureus. The electrocardiograph showed frequently occurring ventricular premature beat, and ultrasonic cardiogram (UCG) showed a spherical cystic echo (82 × 76 mm) at the anterolateral aspect of the ascending aorta (). Then an emergent computed tomography angiography (CTA) was done which revealed an abnormal 86 × 78 mm echo located at the an",
"role": "user"
},
{
"content": " terolateral aspect of the ascending aorta <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "A 62-year-old male patient presented with a large left-sided liver mass (11.3 × 9.1 × 10.5 cm, radiographically), which on biopsy proved to be a well-differentiated HCC (grade 1/4). There was portal fibrosis without bridging formation or cirrhosis in the adjacent liver (ISHAK fibrosis score 1–2/6). Liver function tests were normal at this time. The mass had a well-defined capsule which enhanced on equilibrium phase images. There was no evidence of hepatic or portal venous",
"role": "user"
},
{
"content": " invasion. <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "A 24-year-old married Arab woman had been admitted to a local health center 2 months prior to referral to our urology department. She had been hospitalized there four times in 1 year for acute pyelonephritis. The fourth episode raised the suspicion for an underlying problem and justified her referral to our urology department after management of the acute pyelonephritis.\nOn admission, she complained of ascending left-sided flank pain during micturition but did not have dysuria or hematuria. She also had a history of frequent urinary tract infections (UTIs) as a young adult.\nShe was perfectly asymptomatic on the right side. A physical examination was normal. Her temperature was 37.4 °C, her blood pressure was 128/84 mmHg, and her p",
"role": "user"
},
{
"content": " ulse rate was regular at 76 beats per minute. <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "In the 1998 report on the treatment of B, he was 20 years old. B had been a child with a classical gender dysphoric development and fulfilled the current criteria for GnRH analog treatment eligibility. He was interviewed shortly after his legal gender change. This meant that he had had puberty suppression, cross-sex hormone treatment, a mastectomy, ovariectomy, and uterus extirpation. From his assessment during the diagnostic phase, he appeared to be an intelligent person (IQ = 128) with excellent problem-solving capabilities with respect to emotional matters. Vulnerable aspects of his psychological functioning were his insecurity about himself and moderately depressed feelings. In all other areas, his scores on a broad range of measures were in the average range, as compared to Dutch normative samples. Shame concerning his transsexualism made him highly selective in his friendships and guarded in his contacts with new people. At the assessment, 1 year after his ovariectomy but prior to his metaidoioplasty, he no longer reported feelings of gender dysphoria. He had adjusted easily to the male role and expressed no doubts on the adequacy of his masculine behavior. After the development of his secondary male sex characteristics, nobody had ever approached him as a woman. He never felt any regrets about his d",
"role": "user"
},
{
"content": " ecision and had never contemplated living as a girl again. <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "A 49 year-old Caucasian woman was transferred to our hospital with right flank and lower quadrant abdominal pain in March 2010. Her history was significant for type I",
"role": "user"
},
{
"content": " diabetes mellitus, hypertension, hyperlipidemia, end-stage kidney disease. <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "A 72-year-old slightly obese man with a body mass index of 28.4 presented to our hospital for chest tightness and nausea for 2 weeks. There was no history of thoracic and abd",
"role": "user"
},
{
"content": " ominal trauma. <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "A 61-year-old African American male with past medical history of hypertension and schizophrenia presented to the emergency room following 2 episodes of syncope.\nHe reported 3 month history of progressive neck mass. Physical examination revealed a temperature of 37.7 degrees, blood pressure of 130/87 mmHg, pulse of 92 bpm, and respiratory rate of 17 bpm. There was extremely large left sided neck mass extending into the left axilla and multiple palpable left and right cervical lymph nodes",
"role": "user"
},
{
"content": " . <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "A 52-year-old male presented at the emergency department with since 1 day acute abdominal pain in the left hemi-abdomen. He was nauseous and had vomited. The abdominal pain appeared in attacks and patient was sweaty. His defecation pattern was unchanged and there were no urogenital complaints. There was no history of trauma. Patient did not use any medicine and thus also no ant",
"role": "user"
},
{
"content": " i-coagulants. <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "A 54 year old female presented to our surgical outpatient clinic with abdominal pain and pyrexia. Abdominal pain was of recent onset and mainly in the left upper abdomen but she had fever for at least 6 months. Her pyrexia was h",
"role": "user"
},
{
"content": " igh grade (39. <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "A 17 year-old male presented with a 1-year history of chest pain and dyspnea on exertion. During the past 2 weeks, he had experienced an exacerbation of his symptoms with shortness of breath even at rest, palpitations, pain in the right hypochondrium, abdominal distension, and progressively increasing jaundice.\nOn clinical examination, he was found to be icteric with hepatomegaly and ascites. There was jugular venous distension and bilateral pedal edema. Cardiac auscultation revealed a pansystolic cardiac murmur in the aortic region and along the left lower sternal border suggestive of aortic and tricuspid regurgitation. On transthoracic echocardiography, he was found to have a large blood-filled sac arising from the aortic root with peripheral thrombus and obstruction of the right ventricular out-flow tract (RVOT). There was severe aortic and tricuspid regurgitation.\nContrast-enhanced CT of the thorax was performed to delineate the anatomical relation of the aneurysmal sac and its level of origin. CT showed a large aneurysmal vascular structure measuring 11.8 × 10.1 × 9.2 cm arising from the right coronary sinus. The lumen of the aneurysm was partially opacified by the",
"role": "user"
},
{
"content": " contrast, with a large eccentric non-enhancing thrombus noted <|endoftext|>",
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[
{
"content": "A 65 years old male with history of colitis ulcerosa, and advanced sarcoidosis diagnosed 10 years before, on oral steroids was admitted to our department due to exertional dyspnea and right ventricular (RV) heart failure progressing since last 12 months to functional class IV. Two years earlier, he experienced the first severe decompensation of right heart function. At that time PH was diagnosed on echocardiography. RV to left ventricle (LV) ratio exceeded one (RV:LV - 39/32 mm); peak systolic tricuspid regurgitation gradient (TRPG) was 75 mmHg, and decreased tricuspid annular plane systolic excursion (TAPSE) 15 mm indicated significant pressure overload and RV systolic dysfunction. Chest computed tomography (CT) revealed sarcoidosis progression, however no pulmonary thromboemboli were detected. After typical heart failure treatment with diuretics, ACE inhibitors, and steroid dose increase the patient improved and he was discharged home in a good clinical condition in WHO functional class II, with the diagnosis of PH due to sarcoidosis stage IV. One year later, due to acute dyspnea, worsening of RV function and unilateral leg swelling he underwent another chest CT, which this time showed fresh thrombi in the left s",
"role": "user"
},
{
"content": " egmental upper lobe pulmonary artery. <|endoftext|>",
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}
]
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[
{
"content": "A 26-year-old, otherwise healthy male has reported to the restorative clinic 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",
"role": "user"
},
{
"content": " intake were assessed, and all results came up as normal. <|endoftext|>",
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}
]
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[
{
"content": "The patient was a 5-year-old girl. She was born at 37 weeks of gestation. During the pregnancy, her mother had a history of two risk of miscarriage treated with progesterone. She had not previously been diagnosed with infertility and had not undergone any assisted reproductive technology procedures. The patient was delivered by cesarean section with a birth weight of 2000 g. She did not require resuscitation. She was the first child of healthy non-consanguineous parents. There was no familial history of any neuropsychiatric disease including epilepsy or febrile seizures.\nAt the age of 18 months, she presented with a febrile generalized tonic-clonic seizure (GTCS) for about 2 min associated with herpangina. After that, she had recurrent febrile GTCS for seven times with the duration of 1–2 min and also had a fever without an attack in rare cases. At the age of 5 years and 3 months, she developed the first afebrile seizure, presenting with focal motor seizure with secondarily GTCS for about 2 min at sleep onset. She had a mildly delayed developmental milestone, especially in gross and fine motor skills. Great progress was made after effective training. Developmental regression was noticed after seizures. Now, at the age of 5 years and 11 months, there was no significant delay in gross motor and language skills. But the significant cognitive impairments were noticed, including memory problems, learning disorders, attention span and irritability. She could",
"role": "user"
},
{
"content": " not complete the simple algorithm even less than ten. <|endoftext|>",
"role": "assistant"
}
]
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[
{
"content": "A 78-year-old man was admitted to the pulmonary hypertension service at Stanford Hospital in December, 2010 with elevated pulmonary arterial pressures and progressive right-sided heart failure. He reported progressive shortness of breath over a period of two months, culminating in dyspnea at rest. This was associated with a 20-pound weight gain, abdominal bloating, and leg edema.\nHe was first evaluated for dyspnea several years prior to admission, where he was diagnosed with bilateral pleural effusions and extensive pericardial calcification on chest computed tomography (CT). Echocardiography and cardiac catheterization were consistent with constrictive pericarditis. He subsequently underwent uneventful complete pericardiectomy in 2008. The pericardium was stripped from phrenic nerve to phrenic nerve and the diaphragmatic and posterior pericardium was removed as well.\nThe patient enjoyed symptomatic improvement for approximately one year but then developed recurrent dyspnea. An echocardiogram demonstrated right ventricular (RV) pressure overload and a right ventricular systolic pressure of 66 mmHg. A trial of sildenafil was initiated but was discontinued afte",
"role": "user"
},
{
"content": " r the patient developed a marked worsening of his dyspnea. <|endoftext|>",
"role": "assistant"
}
]
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[
{
"content": "A 21-year-old male patient reported to the department of periodontics with a complaint of bad breath and swelling of the gums for the past 2 weeks of his visit. The patient was apparently normal before 2 weeks after which he noticed spontaneous bleeding from gums while brushing. His medical history revealed that the patient had undergone a renal transplant 1 year ago and was under tacrolimus medication since then. The patient had no deleterious habits and his vitals were normal.\nOn extraoral examination, there were no gross facial asymmetry and no palpable lymph nodes seen. The intraoral examination revealed the presence of generalized, soft, edematous, fibrotic enlargement of the gingiva, involving the marginal, attached and the interdental papilla. The patient demonstrated a poor oral hygiene. Profuse bleeding on probing with a pocket depth varying between 6 and 8 mm throughout the dentition was observed. The hard tissue examination revealed congenitally missing – 12; nonvital – 11; Ellis Class II# in relation to 21. Based on the clinical parameters, it was diagnosed as a case of generalized grade III gingival enlargement [Figure –].\nThe treatment was planned accordingly and was initiated with a Phase I nonsurgical therapy, which included supra- and sub-gingival scaling and root planing and prescribed with 0.2% chlorhexidine mouthwash twice daily for 2 weeks. This was followed by the re-evaluation of Phase I therapy by the end of 2 weeks' interval.\nSurgical excision of the lesion has been planned. The patient was explained about the surgical procedure, and written informed consent form was obtained. Wi",
"role": "user"
},
{
"content": " th the administration of 2% lignocaine (adrenaline <|endoftext|>",
"role": "assistant"
}
]
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[
{
"content": "Patient's consent was obtained to the anonymous use of his clinical data for research purposes.\nA 63-year-old man with a medical history of myocardial surgical revascularization was admitted to our hospital for a COVID-19 pneumonia, which required ventilatory support until the need to wear a continuous positive airways pressure (c-PAP) mask up to 60% FiO2 at day 4. Therapy with hydroxychloroquine 400 mg twice a day, lopinavir/ritonavir 400/100 mg twice a day and antibiotic coverage with ceftriaxone 2 g daily and azithromycin 500 mg daily was set up, according to the internal protocol. Moreover, a 4 French catheter (BD Medical™) was placed in his right radial artery for the arterial blood gas analyses, without any troubles. Then, he received a single dose of tocilizumab 640 mg and started methylprednisolone (40 mg twice a day). The respiratory function progressively improved until a complete weaning from the c-PAP in day 10. The radial artery catheter was removed after 8 days in day 12 without any complications, and local compression was applied to the wrist. How",
"role": "user"
},
{
"content": " ever, on day 14 a painful tumefaction in his <|endoftext|>",
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}
]
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[
{
"content": "An adult captive male bateleur eagle (Terathopius ecaudatus) estimated to be 32 years old and weighing 2.4 kg was presented for evaluation of left hindlimb lameness. The animal had been transferred from another institution 4 weeks prior to presentation with a history of osteoarthritis at the left intertarsal joint and an asymptomatic systolic heart murmur. Laxity and varus deviation of the distal left hindlimb at the intertarsal joint were first observed 2 years prior to presentation at the animal's previous institution. It had also been treated for several previous episodes of bilateral pododermatitis.\nSeveral days after transfer into a new enclosure, the animal began to exhibit intermittent non-weight-bearing left hindlimb lameness and was prescribed tramadol (5.5 mg/kg bodyweight (BW) orally twice daily) for pain management. The animal failed to sufficiently respond to this treatment over the course of 1 month and began spending increased time in a sternal position or on the ground of the enclosure. Under general anesthesia with isoflurane gas and oxygen, a physical examination with radiographs, complete blood count, and plasma biochemistry was performed to evaluate the lameness. Physical examination revealed firm periarticular enlargement, reduced range of motion, subluxation, and dynamic varus deviation at the left intertarsal joint (). No evidence of pododermatitis was observed at either foot. Orthogonal view radiographs of the pelvic limbs revealed muscle atrophy of the left hindlimb, moderate soft-tissue expansion around the left intertarsal joint with an uneven joint space that was widened at its lateral and narrowed at its medial aspects on the dorsoplantar radiographic view, and evidence of degenerative joint disease at this joint (). A compl",
"role": "user"
},
{
"content": " ete blood count and plasma biochemistry <|endoftext|>",
"role": "assistant"
}
]
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[
{
"content": "A 57-year-old man presented with a chief complaint of a growth in his lower left back tooth region of 15 days duration. The growth h",
"role": "user"
},
{
"content": " ad started insidiously and gradually increased to reach <|endoftext|>",
"role": "assistant"
}
]
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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 ",
"role": "user"
},
{
"content": " ]. <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "A 68-year-old female patient with a history of congenital hearing loss presented to the otology clinic to discuss management of her hearing loss. She had previously been di",
"role": "user"
},
{
"content": " agnosed with ossicular and cochlear malformation but had <|endoftext|>",
"role": "assistant"
}
]
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[
{
"content": "A 13-day-old male Holstein calf presented with a horn-like mass in the left and rostral maxillary gingiva (Fig. ). The calf had good weight gain, and showed normal eating and drinking behavior, although a small amount of hemorrhage was found near the top of the mass during eating. Respiratory signs including cough, and dyspnea were not evident. The horn-like mass was 1.5 cm in width and 3.5 cm in height, and was colored similar to the gingival mucosa. On palpation, the mass was firmly fixed with the deeper structures. Palpation did not reveal whether the mass was derived from maxillary bones, although a hard structure could be felt inside of the mass. Under sedation with intravenous xy",
"role": "user"
},
{
"content": " lazine hydrochloride (0. <|endoftext|>",
"role": "assistant"
}
]
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[
{
"content": "A 12-year-old Japanese girl, gravida 0 para 0, who was the monozygotic twin sister of the patient in Case 1, visited our gynecologic department for ovarian screening 3 months after the first operation of Case 1. Transrectal echography revealed bilateral ovarian cystic tumors with calcified structures. Tumor marker levels (CA125, SCC, CEA, and CA19-9) were normal. The bilateral ovarian cystic walls were extracted, and normal ovarian tissues were preserved by laparotomy. Pathological anal",
"role": "user"
},
{
"content": " ysis of the cyst wall disclosed that there <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "An 18-year-old male presented with complaints of sub-acute onset, moderate to severe, occipitonuchal headache associated with vomiting and low grade fev",
"role": "user"
},
{
"content": " er 1 year back. <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "White blood cell count 5.8 hematocrit 23.5 platelet count 118 . Sodium 140 potassium 3.9 chloride 103 bicarbonate 18 BUN 11 creatinine 0.8 glucose 144 . PT 29 INR 1.1 and PTT 22.9 . Neurologically the patient is alert and oriented times three anxious . Neurological examination is non-focal . Heart is regular rate and rhythm without rub or murmur . Respiratory breath sounds are clear bilaterally decreased at the bases . Abdomen with positive bowel sounds soft nontender nondistended tolerating a regular diet . Sternal incision staples are intact and open to air . Incision is clean and dry . There is no erythema and sternum is stable . Right lower extremity vein harvest site has a moderate amount of ecchymosis at the very distal portion of the incision a",
"role": "user"
},
{
"content": " t the ankle . <|endoftext|>",
"role": "assistant"
}
]
|
[
{
"content": "A 74-year-old man was referred to the opthalmology clinic with a history of a mass in the left upper eyelid that had been present for four years. Visual acuity was 7/10 for the right eye and 6/10 for the left eye, anterior segment examination revealed grade 2 nuclear cataract for the right eye and grade 3 nuclear cataract for the left eye. Motility was bilateral normal with no diplopia. Levator functions were bilateral normal, except there was a minimal mechanical ptosis for the left eye. There was also a subcutaneous mass on the left forearm. Systemic check-up relevead no other illness or malignancy. On clinical examination, there was a subcutaneous, firm and round mass located on the central left upper eyelid, which was non-tender to palpation. It was inconspicuous on inspection. There was no eyelid movement restriction but a feeling of friction on the superior orbit during lid movement. Ultrasonography showed a homogeneous echogenic and well defined mass in the anterior orbit. No internal vascularity was seen. An excisional biopsy was taken through the crease of the upper eyelid under local anesthesia. The lesion was 9x7x7 mm in diameter and located 15 mm superior to the eyelid margine and located under the orbicularis muscle. During the",
"role": "user"
},
{
"content": " removal operation, it was noted that the <|endoftext|>",
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}
]
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[
{
"content": "The patient was a 72-year-old man who was followed up for persistent pain in the left side of the waist for 2 years, radiating to the left hip. The history of schistosomiasis was 40 years, and with hypertension 1 year. On physical examination, he had pain on movement of the spine with bilateral Grade IV motor strength in both lower extremities. There was not numbness in both feet and ankles with normal ankle reflexes bilaterally. There was a normal knee reflex bilaterally. There was no obvious bulge in the bilateral kidney region, and the left lateral kidney region knocks out to be positive for pain. The neurological symptoms were ascribed to the compression of the spinal cord and nerve roots by an expanding mass partly protruding into the vertebral canal.\nMagnetic resonance imaging (MRI) was performed that the left side of the vertebral body and the left peritoneum showed an elli",
"role": "user"
},
{
"content": " ptical abnormal signal shadow, which showed a dumbbell growth. <|endoftext|>",
"role": "assistant"
}
]
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[
{
"content": "The second case is that of an 8-year-old female with a history of juvenile rheumatoid arthritis, ",
"role": "user"
},
{
"content": " scleroderma, bilateral genu valgum, and right <|endoftext|>",
"role": "assistant"
}
]
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[
{
"content": "A 68-year-old female diagnosed with advanced RCC, Level IV, presented for right radical nephrectomy, lymph node dissection, vena cava, and RA tumor thrombectomy. Preoperative contrast-enhanced computed tomography revealed the tumor extension into the IVC up to the RA. Echocardiogram revealed a 2.6 cm × 2.3 cm × 2 cm mass in the RA reaching into the IVC. A transplant anesthesiologist with support from a cardiac anesthesiologist was assigned to the care of the patient. Following the induction of general anesthesia, a radial arterial line and 9 Fr internal jugular central line were inserted. In addition, a multiplane TEE probe was placed in the esophagus. Initial TEE examination of the heart confirmed the normal cardiac structures and function without a patent foramen ovale. TEE study was performed with emphasis on the hepatic veins, IVC, right side of the heart, and pulmonary arteries (PAs). The tumor was well-visualized in the IVC extending proximal into the RA as depicted in the midesophageal bicaval view [, Arrow].\nSurgery proceeded with a bilateral subcostal anterior incision with cardiothoracic surgical team and cardiopulmonary bypass team placed on standby. Using the methods adopted from liver transplantation surgery “piggyback technique,” the liver was mobilized, hepatic veins were exposed, and the IVC was isolated with subsequent vascular exclusion of the liver. After clamping the renal vein and IVC distal to the kidney, a clamp was applied at the cava-atrial junction under TEE surveillance; to ensure that the tumor was entirely isolated below the cl",
"role": "user"
},
{
"content": " amp. <|endoftext|>",
"role": "assistant"
}
]
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[
{
"content": "A 62-year-old woman undergoing presurgical evaluation for an olfactory groove meningioma resection was incidentally found to have a pancreatic mass on an abdominal CT in April 2009. The 2.9 × 2.5 cm mass was centered in the pancreatic body with a round shape, well-defined margins, and avid homogenous enhancement (). There was mild upstream pancreatic duct dilation. There was no lymphadenopathy in the abdomen and pelvis or other signs of another primary tumor or metastatic disease. Differential considerations offered included either a neuroendocrine tumor or a vascular abnormality such as an aneurysm or pseudoaneurysm. An endoscopic ultrasound performed at the time revealed a 2.2 cm well-defined solid hypoechoic mass in the pancreatic body, suspicious for a pancreatic neuroendocrine tumor. Fine needle aspiration of this mass showed no evidence of a malignancy, but only changes of chronic pancreatitis. The patient's abdominal physical examination was normal, and she denied any abdominal pain, weight loss, diarrhea, or constipation. Repeat CT in October 2013 demonstrated mild interval increase in size of the mass to 3.0 × 3.0 cm. An endoscopic ultrasound was repeated in December 2013, confirming an increase in size of the solid mass (). Repeat fine needle aspiration of the mass yielded only atypical epithelial cells. The patient's c",
"role": "user"
},
{
"content": " omplete blood count, complete metabolic <|endoftext|>",
"role": "assistant"
}
]
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[
{
"content": "We present the case of a 57-year-old gentleman who was admitted from the community with a 5-day history ",
"role": "user"
},
{
"content": " of worsening lower back pain. <|endoftext|>",
"role": "assistant"
}
]
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[
{
"content": "A 37-year-old Chinese woman was evaluated for right tonsil swelling and a sore throat in our hospital. She was diagnosed in September 2011 with rectal cancer revealed by generalized peritonitis evoked by tumor perforation. At diagnosis, the preoperative evaluation did not show distant metastasis (M0). The patient underwent an urgent exploratory laparotomy. The tumor measuring 10.0 cm×4.0 cm×3.5 cm was identified at the anterior rectal wall under the peritoneal reflection intraoperatively. A low anterior resection using a total mesorectal excision technique was performed, with a colostomy using noninflamed descending colon, and the divided end of the rectum was closed. The excised specimen contained a poorly differentiated adenocarcinoma invading into nonperitonealized perirectal fat with negative surgical margins (T3). Nine regional lymph nodes were positiv",
"role": "user"
},
{
"content": " e for tumor extension (N2b). <|endoftext|>",
"role": "assistant"
}
]
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[
{
"content": "A 21-year-old woman was referred with an occasionally painful right loin mass, persistent microscopic haematuria and lower urinary tract symptoms of 3-month duration. She reported increasing breathlessness and felt dizzy whilst carrying out routine activities. Clinical examination revealed only a weak radial pulse and a palpable right renal mass with no ascites or peripheral oedema.\nUltrasound scan (USS) revealed a large 11 cm mass arising from the lower aspect of the right kidney, which extended along the right renal vein and into t",
"role": "user"
},
{
"content": " he inferior vena cava (IVC) and up to the diaphragm. <|endoftext|>",
"role": "assistant"
}
]
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[
{
"content": "We report the case of a 29-year-old female patient with lymphedema of the lower limbs. The patient arrived at the Clinica Godoy in Sao Jose do Rio Preto for treatment in January 2011. The patient reported that the lymphedema started at the age of 12 or 13 years old when she was submitted to a surgery to remove a tumor in the abdomen, which started with pain and the diagnosis of appendicitis. During surgery a lymphoma was identified. After surgery, the patient was submitted to chemotherapy and radiotherapy sessions; she does not remember how many sessions due to her age at that time; her mother, who accompanied her, has passed away. The patient reported that the swelling began in the thigh region a",
"role": "user"
},
{
"content": " nd spread to the feet; initially <|endoftext|>",
"role": "assistant"
}
]
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[
{
"content": "A 14 year old Caucasian female presented to our pediatric scleroderma clinic with a 4 year history of progressive mixed morphea, a combination of generalized plaque morphea and linear scleroderma of the trunk/ extremities. Her condition started as a single bruise-like lesion over the right flank, and despite systemic therapy, had advanced to cover approximately 80% of her body surface area.\nA deep punch biopsy of the initial lesion demonstrated histologic findings consistent with LS (morphea), including full thickness dermal fibrosis with a superficial and deep perivascular lymphohistiocytic infiltrate. In addition, there was thickening of the fibrous septa in the panniculus with aggregates of plasma cells at the edges, supporting deeper involvement. An eosinophilic infiltrate was not present in the subcutis. She was initially treated",
"role": "user"
},
{
"content": " with topical corticosteroids, but these were discontinued due <|endoftext|>",
"role": "assistant"
}
]
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[
{
"content": "A previously healthy 6-year-old boy presented to a pediatric hospital with a 3-week history of torticollis. He had symptoms of an upper respiratory tract infection four weeks prior and had 2 days of documented fever at home during that time. He had been treated with a 7-day course of amoxicillin by the primary care physician for suspected streptococcal ph",
"role": "user"
},
{
"content": " aryngitis. <|endoftext|>",
"role": "assistant"
}
]
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[
{
"content": "A 39-year-old Caucasian female presented with a 5-week history of worsening right-sided abdominal pain, which she described as sharp and burning, without radiation. There were no associated fevers, chills, nausea, vomiting, diarrhea or hematoc",
"role": "user"
},
{
"content": " hezia. <|endoftext|>",
"role": "assistant"
}
]
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[
{
"content": "An 87-year-old man with a past medical history significant for chronic obstructive pulmonary disease (COPD), myelodysplastic syndrome (MDS) and subsequent anemia of chronic disease, pulmonary nodule, obstructive sleep apnea (OS",
"role": "user"
},
{
"content": " A), coronary artery bypass grafting (CABG), <|endoftext|>",
"role": "assistant"
}
]
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[
{
"content": "A 47-year-old female presented to the emergency department after developing loss of consciousness with amnesia following several days of right loin pain and fevers. She awoke with left sided facial pain and a dull headache. She could not recall the prior events of the past day but was aware of blood stains on her bathroom floor. She did not report any eye pain or visual loss.\nShe had a previous ischaemic stroke and was being managed for hypertension and type 1 diabetes with secondary nephropathy requiring line dialysis. She has bilateral proliferative diabetic retinopathy and is registered as blind. Her left eye had undergone panretinal photocoagulation, delamination, and vitrectomy with internal air tamponade. Her right eye had undergone delamination and segmentation with silicone oil tamponade. All procedures occurred within the previous two years.\nShe was taking insulin and dual antiplatelet therapy. She lived alone and was independent with her activities of daily living.\nOn examination, there was bilateral periorbital bruising but no ophthalmoplegia. Blood pressure was 159/102 mmHg. Ophtha",
"role": "user"
},
{
"content": " lmology examination showed bilateral conjunctival haemorrhages in <|endoftext|>",
"role": "assistant"
}
]
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[
{
"content": "A 54-year-old woman was admitted to our hospital complaining of intermittent palpitation which began 6 years ago and aggravated during the last 2 months. After the first symptom, she visited a local clinic and her symptom was managed under the impression of cardiac arrhythmia. But one year later, she discontinued anti-arrhythmic medication on her own. Until two months before admission, she had experienced intermittent palpitation again but it did not interfere with her life. Afterwards, palpitation became more severe suddenly and squeezing anterior chest tightness radiating to the left axilla developed and continued for about 10 minutes.\nThe patient was a housewife and had no history of smoking or alcohol consumption. There was no specific problem in her past medical and family history. The body temperature was 36.5°C and the heart beats were irregularr and rated over 140/min. On physical examination, mild moist crackling sounds were heard below a third on the back bilaterally. Neck vein engorgement was also seen. Considering the chest pain as ischemic in nature, nitroglycerin was given sublingually and the pain subsided. ECG showed atrial fibrillation with rapid ventricular response. Cardiomegaly with pulmonary vascular blurring and redistribution was seen on chest X-rays (). Other laboratory data, including cardiac enzymes and thyroid function tests, were within normal limits. Initially, cardiac tumor was not considered as the differential diagnosis. Transthoracic echocardiography, which was performed after her symptom had disappeared, showed normal global left ventricular systolic function (ejection fraction: 63%) with left ventricular enlargement and hypertrophy, and also showed",
"role": "user"
},
{
"content": " trivial mitral regurgitation. <|endoftext|>",
"role": "assistant"
}
]
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[
{
"content": "A 49-year-old male with history of alcohol-induced pancreatitis presented with 1 month of worsening left pleuritic chest pain and shortness of breath. Initial physical exam was unremarkable, and laboratory tests were only remarkable for increased lactate dehydrogenase and borderline-low albumin. Initial chest radiograph showed moderate left and small right pleural effusions with left retrocardiac opacity (). Computed tomography (CT) pulmonary angiogram was performed and was negative for pulmonary embolism and showed only small bilateral pleural effusions.\nOn admission, patient underwent thoracentesis and approximately 1L of brown fluid from the left pleural space was removed. Pleural fluid evaluation demonstrated an exudative effusion with lipase of 2912 IU/L and amylase of 2783 IU/L. CT abdomen and pelvis demonstrated a fluid density tract arising from the pancreatic tail, extending caudally through the diaphragm from the esophageal hiatus, communicating with the left pleural space (). The patient was started on medical therapy with octreotide. Magnetic resonance cholangiopancreatography (MRCP) confirmed a PPF tract with irregular, dilated, main pancreatic and common bile ducts (). The patient underwent ERCP two days after admission which redemonstrated mild diffuse dilatation of ventral pancreatic duct involving the head, body, and tail of the pancreas with evidence of pancreatic duct leak in the most upstream tail of the pancreas that extended caudally to the left pleural cavity, consistent with PPF. A 5 FR x 10 cm plastic stent was placed in the pancreatic duct and a biliary and pancreatic sphincterotomy was performed to divert the fluid leak.\nThe hospital course was complicated by post-ERCP acute pancreatitis, which was treated with bowel rest and empiric antibiotics. Postprocedure chest radiograph showed worsening pleural effusions and surgical management including distal pancreatectomy was considered. However, surgery was deferred after the patient improved clinically with medical management, and a repeat chest radiograph revealed improvement of the pleural effusions. Th",
"role": "user"
},
{
"content": " e patient improved clinically and was discharged with pain medications. <|endoftext|>",
"role": "assistant"
}
]
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[
{
"content": "Systemically healthy 24-year-old male patient came to Department of Periodontics, with the complaint of unaesthetic appearance of upper central teeth because of forwardly placed maxillary left central incisor since 6 months. Patient gave history of extraction of supernumerary tooth, which was placed palatal to 11 and 21, 3 months back. 21 had gradually come to the present position over 6 months []. Patient was also complaining about functional problems of the upper central teeth because of loss of biting ability due to forwardly placed and mobile tooth. During the clinical examination, approximately 6 mm of periodontal pocket were observed with 21. Radiographic examination was revealed moderate alveolar bone resorption reaching to the middle third of the tooth []. Mobility of the tooth was Grade II.\nPatient demanded not to loose any teeth because of psychological reasons during the treatment plan phase. Considering patient's demands and the clinical situa",
"role": "user"
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"content": " tion, the treatment plan of upper anterior teeth (21) decided <|endoftext|>",
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[
{
"content": "A 63-year-old male with no history of trauma or prior neurological disease presented with 3 days of intermittent dizziness and vomiting. On the second day, the patient was examined by a head computed tomography (CT) scan, and no abnormal changes were found. Five days later, the patient had a sudden onset of weakness in his right limbs, followed by an episode of focal seizure without impaired awareness. The patient had symptomatic deep venous thrombosis (DVT) in the left lower limb 4 years ago, which was treated with warfarin for 3 months. No secondary prophylaxis was subsequently applied, and as a result he experienced multiple recurrences of lower limb DVT. The patient also had a 5-year history of hypertension without antihypertensive therapy. He also had a 2-year history of Raynaud’s phenomenon in his hands, as well as a 30-year history of smoking (10 cigarettes per day) and alcohol intake (50 g per day). The patient’s parents had died of ICH. Additionally, the patient’s three sisters were diagnosed with hypertension, and one brother had a history of occlusion of the distal artery in the right leg at the age of 55 years. The patient’s son had their first symptomatic lower limb DVT at the age of 25 years, for which he underwent inferior vena caval filter placement.\nUpon examination after admission, the patient had a blood pressure of 164/92 mmHg. Skin color, temperature, and peripheral pulses were normal. No varicose veins or swelling of the li",
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{
"content": " mbs were found, and the <|endoftext|>",
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[
{
"content": "A 32-year-old male patient reported to the outpatient department with a chief complaint of a painless, slow growing swelling in the maxillary anterior teeth region for the past 6 months. The swelling was initially small in size and had increased with time to attain the present size. There was no associated history of trauma and pain. The medical history was noncontributory. Extra oral examination revealed diffuse swelling in the anterior region of the maxilla. Anteriorly, the swelling extended from the tip of the nose to 2 cm lateral to the left ala of the nose posteriorly, and superiorly extending up to 3 cm inferior to the left inner canthus of the eye, and inferiorly it extended to the lower border of the upper lip. The swelling caused mild deviation of the tip of the nose to the right side with obliteration of the left nasolabial fold. On palpation, the swelling was nontender and firm in consistency []. Intraoral examination revealed a well-defined solitary swelling in the region of the maxillary vestibule measuring 3.5 cm2 × 3 cm2 in size. It extended from 11 to the distal line angle of 23. The swelling obliterated the labial mucobuccal fold superiorly and inferiorly it extended to the region of the alveolar mucosa. The overlying mucosa was intact and of the same color. No",
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"content": " surface discharge was seen. <|endoftext|>",
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[
{
"content": "A 19-year-old female patient reported to the Department of Oral Medicine and Radiology, K.S.R Dental College and Hospital with the chief complaint of missing teeth in the upper and lower jaw since childhood; she had difficulty in mastication and was feeling esthetically ill. Her medical history revealed that in her childhood she had recurrent history of fever followed, which she visited a physician and the investigation was carried out and diagnosed to have Langerhans cell histiocytosis. History reveals that she had lesions in the skull and mandible at the age of 3 years and was treated with a combination of radiotherapy and chemotherapy radiotherapy of 50 Gy was given in divided doses for a period of 1 year and chemotherapy for about 1 year, patient was under review for about 10 years with no recurrence. Her dental history was not contributory; she gave a history of spontaneous exfoliation of her few deciduous teeth, followed by delayed eruption of permanent teeth. On general examination, patient was normal in stature, appearance and gait. On extra oral examination facial asymmetry was noticed on the left side of the face (the radiation exposed side) [] temporomandibular joint movements were normal and on right and left side deep sigmoid notch was present but more prominent on the left side. On intra oral hard tissue examination revealed clinically present 11, 13, 15, 16, 17, 23, 26, 31, 33, 34, 36, 41, 42, 43, 46, 47 and RS in 62. Hence, there was hypodontia, microdontia of all the teeth and spacing between the teeth [Figures and ].\nOrthopantomogram r",
"role": "user"
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"content": " evealed (a) hypodontia (b) hypoplasia of <|endoftext|>",
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[
{
"content": "The 83-year-old patient presented herself at a neurological emergency department with bilateral blindness and a history of severe headache, which she described the day before. An urgent computed tomography (CT) scan of the brain had been arranged, and a massive pituitary adenoma with hemorrhage was observed, and admission to the neurosurgical department immediately followed. When arriving at the hospital the hemodynamic parameters were stable (BP 130/90, 65 BPM); Glasgow coma score was 14/15. Her medical history included chronic renal failure (III°) as well as cardiovascular disease with hypertension, chronic atrial fibrillation, coronary heart disease with percutaneous transluminal coronary angioplasty, and stent. Therefore, dual oral anticoagulation with clopidogrel and acetylsalicylic acid was administered. Multiple electrode aggregometry did not detect effects of both anticoagulants. The neuro-ophthalmic examinat",
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"content": " ion revealed no perception of light in both eyes. <|endoftext|>",
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[
{
"content": "A 40-year-old Hispanic man with a past medical history of human immunodeficiency virus (HIV) was brought to the emergency department complaining of right upper extremity (RUE) weakness and numbness for four days with associated bitemporal headache and generalized fatigue. The patient reported first time use of intranasal cocaine and heroin, after which he lost consciousness and woke up approximately four hours later with new onset RUE and headache. His cluster of differ",
"role": "user"
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{
"content": " entiation 4 (CD-4) count was reported above 500 cells/mm3 and <|endoftext|>",
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[
{
"content": "A seventy-eight-year-old female patient with a previous medical history of diabetes mellitus, hypertension, ischemic heart disease, and Hypothyroidism presented with a one-week history of abdominal pain and nausea with vomiting following meals. Her symptoms progressively worsened to severe abdominal distention, anorexia and obstipation on the day of admission. She had no fever, chills, bleeding per rectum, or previous abdominal surgeries. Four weeks earlier the patient had similar symptoms. A plain abdominal X-ray and CT scan which were done at that time showed dilated small bowel loop in right lower quadrant without detected lesions or significant wall thickening, and she had been treated conservatively. After resolution of her symptoms—during the previous episode—an upper and lower GI endoscopy were done and revealed moderate erosive esophagitis, Helicobacter pylori positive gastritis and duodenitis, and an essentially normal colonic exam.\nHer vital signs on admission were within normal limits. Examination showed a distended abdomen with hyperactive bowel sounds and generalized tenderness without peritoneal signs. Her laboratory investigations showed anemia with hemoglobin of 7.2 g/dL and white cell count of 9.9 × 103/mm3. Abdominal X-ray revealed dilated proximal bowel loops with multiple air fluid levels. Conservative measures with bowel rest, nasogastric intubation, and intravenous fluids failed to control her symptoms. Abdominal and pelvic CT-scan showed markedly dilated fluid filled small bowel loops with one loop showing central hyperdense area, and a thick soft tissue mass around it with multiple small hypodense areas, referred to as the target sign [] ().\nDiagnostic laparoscopy which revealed a distal jejuno-jejunal intussusception was followed by limited laparotomy and resection then anastomosis was performed (). The leading point of the invagination was jejunal tumor (). Histopathologic examination of the resected specimen revealed a GIST of intermediate risk, and resection was complete with viable ends.\nThe patient had an uneventful postoperative recovery and was discharged in a well conditio",
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{
"content": " n. <|endoftext|>",
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