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

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

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

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

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[{"content":"**Dear colleague, **\n\nWe are reporting on Mr. Bruno Hurley, born on 12/24/1965, who h(...TRUNCATED)

{"options":{"A":"Azacitidine","B":"Levofloxacin","C":"Rifampicin","D":"Ethambutol","E":"Pyrazinamide(...TRUNCATED)

[{"content":"\nPlease answer the following query based on the provided context:\n\nHere is the conte(...TRUNCATED)

[{"content":"**Dear colleague, **\n\nWe report about your outpatient treatment on 09/01/2010.\n\nDia(...TRUNCATED)

{"options":{"A":"The CT scan showed signs of liver metastases.","B":"The CT scan indicated remission(...TRUNCATED)

[{"content":"\nPlease answer the following query based on the provided context:\n\nHere is the conte(...TRUNCATED)

[{"content":"**Dear colleague, **\n\nWe would like to inform you about our patient, Mr. Peter Rudolp(...TRUNCATED)

{"options":{"A":"2010","B":"2012","C":"2013","D":"2019","E":"2020"},"patient_birthday":"05/26/1954",(...TRUNCATED)

[{"content":"\nPlease answer the following query based on the provided context:\n\nHere is the conte(...TRUNCATED)

[{"content":"**Dear colleague, **\n\nWe would like to inform you about our patient, Mr. Peter Rudolp(...TRUNCATED)

{"options":{"A":"Chest CT < Chest CT < CT-guided liver biopsy < Abdominal CT","B":"Chest CT < Abdo(...TRUNCATED)

[{"content":"\nPlease answer the following query based on the provided context:\n\nHere is the conte(...TRUNCATED)

[{"content":"**Dear colleague, **\n\nWe are reporting on Mr. Ben Harder, born on 08/02/1940, who was(...TRUNCATED)

{"options":{"A":"Decrease in metabolic activity","B":"New extensive metastasis in the sacrum","C":"N(...TRUNCATED)

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[{"content":"**Dear colleague, **\n\nWe would like to inform you about our patient, Mr. Peter Rudolp(...TRUNCATED)

{"options":{"A":"Diagnostic ureterorenoscopy on the left","B":"Biopsy of the left ureter","C":"Retro(...TRUNCATED)

[{"content":"\nPlease answer the following query based on the provided context:\n\nHere is the conte(...TRUNCATED)

[{"content":"**Dear colleague, **\n\nPatient: Miller, John, born 04/07/1961\n\nWe report to you abou(...TRUNCATED)

{"options":{"A":"169 cm","B":"160 cm","C":"180 cm","D":"175 cm","E":"170 cm"},"patient_birthday":"19(...TRUNCATED)

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[{"content":"**Dear colleague, **\n\nWe are reporting on the patient Mr. George Davies, born on 07/2(...TRUNCATED)

{"options":{"A":"Increased from 1.10 mg/dL to 1.22 mg/dL","B":"Decreased from 1.22 mg/dL to 1.10 mg/(...TRUNCATED)