Datasets:

hippocrates

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Multicare_common_train

like 0

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: At 2 weeks of life (WOL), thyroid function was tested while receiving biotin: TSH was 3.39 mIU/mL and FT4 was elevated at 5 ng/dL. Autoimmune evaluations for hyperthyroidism in the mother and child were negative. At 3 WOL, biotin was withheld for 3 days and repeat thyroid function tests showed a TSH of 5.1 mIU/mL and that FT4 had normalized to 2.4 mIU/mL. At 8 WOL, after biotin was withheld for 4 days, TSH was now elevated and FT4 remained in the reference range. The patient's parents reported difficulty in administering the dose via a crushed tablet in a bottle of formula. At 16 WOL, biotin was withheld for 4 days and repeat thyroid function tests showed that TSH was suppressed and FT4 was slightly elevated. The dose of L-T4 was reduced to 12.5 microg (half tablet) and at 20 WOL, after biotin was withheld for 4 days, repeat thyroid testing again showed suppressed TSH and elevated FT4. The parents still reported difficulty with cutting and crushing the L-T4 tablet, resulting in inconsistent dosing. A referral to pediatric endocrine care was then initiated and the L-T4 tablet formulation was changed to oral solution 13 microg daily. The parents reported that administration was much easier with the oral formulation. At 24 WOL, biotin was again withheld for 4 days and repeat thyroid function tests showed normalization in both TSH (1.75 mIU/mL) and FT4 (1.96 ng/dL). At 28 WOL, after biotin was withheld for 4 days, both TSH and FT4 were still normal and the family reported being very happy with the L-T4 oral solution. A timeline of treatments administered along with outcomes is shown in Table 1 and Figure 1.\nOUTPUT:" }, { "from": "agent", "value": "Congenital Hypothyroidism, Trisomy 21, Biotinidase Deficiency" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 43 year old female patient was admitted with history of pain at proximal thigh for the last 30 days. There was no history of trauma in the proximal thigh region. No history of fever and weight loss was described. On physical examination, a mass was palpated over greater trochanter. It was 4 x 5 cm mass, painful, and erythematous. Range of motion of left hip was full and painless. Investigations revealed that CBC (complete blood count), electrolytes, alkaline and acid phosphatese levels were within normal limits. Sedimentation rate was 40 mm in the first hour. X-ray of left hip was normal. Abdominal ultrasonography did not reveal any abnormality. CT scan demonstrated cystic structure close to vastus lateralis muscle (Figure 1). CT showed no involvement of lung and brain. Ultrasonographic examination of the mass showed a cystic structure. Hemoagglutination tests for echinococcosis and ELISA were negative. The patient underwent surgery for excision of the cyst. Following irrigation of cystic cavity with hypertonic saline solution, the cyst wall was excised along with a portion of the vastus lateralis muscle. Histopathological examination of the specimen revealed fibrosis, necrosis, histiocyte cell clusters, mixed type of inflammatory cells, fibroblastic activity and vascular proliferations in adipose and connective tissues. A pericystic structure which consisted of connective tissue and scattered hyaline cells showed a necrotic basophilic structure which resembled cuticular membrane. Scoleces were also detected within the surgical specimen. Hemorrhagic areas were seen within the periphery of cyst. (Figure 2). A high dose of albendazole was initiated for 4 weeks, and a favorable response was obtained. During the follow-up period, chest radiography, abdominal and proximal thigh ultrasonography (US), routine blood biochemistry (glucose, ALT, AST, alkaline phosphatase, blood urea nitrogen, serum creatinine, total protein, albumin and indirect hemoglutination test were performed.\nOUTPUT:" }, { "from": "agent", "value": "Primary subcutaneous cyst hydatic disease in proximal thigh, Echinococcus granulosus infection" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A previously healthy 33-year-old Japanese woman had a fever (38.4 C) 1 week after an uncomplicated spontaneous vaginal delivery without episiotomy at a private clinic. She was transferred to Tokyo Women's Medical University Hospital. On admission, the patient was awake and alert. Her body temperature was 38.8 C, blood pressure was 80/52 mmHg, heart rate was 127 bpm, and respiratory rate was 28 times/min. A diffuse erythematous rash was present on the chest. It spread to the face and extremities and resolved after 8 days. A pelvic examination disclosed a brownish discharge from the cervix. The uterus was approximately 6 cm x 8 cm in diameter, with no tenderness. The laboratory test results and clinical symptoms suggested a diagnosis of TSS (Table). To treat the hypotension, dopamine and fresh frozen plasma were administered. The patient also received antithrombin III, ulinastatin, and gabexate mesilate as well as antibiotics (initially, imipenem/cilastatin 2 g/day + amikacin 200 mg/day, and subsequently, vancomycin 2 g/day). One day after admission, bacteriologic tests showed that the vaginal discharge and breast milk were positive for MRSA. On day 5 after admission, peripheral blood mononuclear cells were examined for expansion of Vbeta2 T cells. A marked expansion of Vbeta2 T cells was confirmed (Figure), indicating the definitive diagnosis of TSS. The Vbeta2-positive T cells gradually diminished to normal levels. Desquamation of the extremities occurred on day 11 after admission. From day 3 after admission, the patient's general condition improved gradually, and she was discharged on day 14. She had no long-term sequelae. Isolates of MRSA isolated were later found to be TSST-1-positive.\nOUTPUT:" }, { "from": "agent", "value": "Toxic shock syndrome" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 71-year-old retired welder with a 28-year history of alopecia universalis developed poison ivy on the right forearm. Three weeks later, after complete healing of the poison ivy, the patient noted pain, redness, and tenderness of his right ear. The earlobe was spared. Shortly thereafter, the patient's nose became red and tender, and his left ear developed similar changes (Figure 1). He was treated with antibiotics with no improvement. One week later, prednisone therapy was begun at a dose of 40 mg per day. Prompt resolution of his signs and symptoms occurred. One month later, as prednisone therapy was being tapered, the patient developed hoarseness and a severe sore throat. Rigid telescopy in the ENT clinic found marked swelling of the arytenoids and false vocal cords. Corticosteroids were increased with resolution of his symptoms. Still later, iritis of the left eye occurred. The patient's eye symptoms responded promptly to an increase in corticosteroid therapy. Interestingly, after six weeks of prednisone 30 mg per day, the patient's beard regrew and he shaved for the first time in 28 years! (Figure 2) There was no regrowth of hair on other parts of his body, including the scalp, axillae, eyelashes, or perineal area. Eleven months into the patient's illness, he developed profound sensorineural hearing loss in both ears. An autoimmune basis for his complaints was suspected. There was no history of fever, weight loss, prior similar symptoms, wheezing, or shortness of breath. The physical examination was unremarkable. Routine laboratory studies that were normal or within the expected range included complete blood count, comprehensive metabolic profile, urinalysis, prostate-specific antigen, thyroid stimulating hormone, c and p antineutrophilic cytoplasmic antibodies, and protein-electrophoresis with immunoglobulins. Sedimentation rate was 43 mm/hr and the antimicrosomal antibody test was positive at 1 : 400 dilution. Pulmonary function tests showed a forced expiratory volume of 78% of predicted and the vital capacity was 71% of predicted, and the carbon monoxide diffusion test was normal. An antibody type II collagen was strongly positive at 65 eu/mL (positive greater than 25 eu/mL). A chest roentgenogram was normal.\nOUTPUT:" }, { "from": "agent", "value": "Relapsing polychondritis" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 58 year old man presented with a slow growing mass on the left forearm. It appeared two years prior to presentation. He experienced no pain or limitations in activities. There was no preceding trauma, and there were no complaints of skin changes. His past surgical history was significant for a radical left nephrectomy done 10 years previously for RCC (clear cell type, Fuhrman nuclear grade 2). Routine annual surveillance was negative for local recurrence or distant metastases. On physical examination, there was a solitary swelling on the volar aspect of the proximal left forearm, measuring approximately 4 cm in length and 3 cm in diameter. The overlying skin was normal. It was not tender, with a smooth surface. The mass appeared to be pulsatile, and was compressible, with immediate refill. There was no thrill or bruit. Ultrasound revealed a solitary, heterogeneous, ovoid intramuscular lesion with increased signal on colour Doppler. Subsequent magnetic resonance imaging showed a well defined fusiform lesion with heterogenous signal intensity within the left brachioradialis muscle (Fig. 1). Intense enhancement was seen post-gadolinium administration. Areas of flow void were also seen, which suggested the possibility of a fast flowing vascular malformation. There was no marked surrounding oedema to indicate surrounding muscular infiltration. From the imaging, it was concluded that although there was a possibility of it being a hypervascular mass, as the features of the lesion were more benign in nature, a fast flow vascular malformation was more likely. Excision of this lesion was performed under general anaesthesia. Intra-operatively there was a benign looking lesion, with a smooth surface, encapsulated by a thick fibrous wall (Fig. 2). It measured 4 cm in length by 2 cm in diameter by 1.7 cm in thickness. It was pulsatile and compressible, with immediate refilling with blood. The main feeding vessel was seen to arise from the recurrent radial artery. The entire lesion was removed successfully, after ligation of its feeding branches. Recovery from the operation was uneventful. Surprisingly, histopathological examination of the specimen was consistent with metastatic RCC (Fig. 3). An urgent staging computed tomography scan showed widespread metastatic disease in the vertebrae and lungs. Oncology referral was sought, and tyrosine kinase inhibitor therapy was initiated. Unfortunately, the disease progressed; with development of symptomatic metastases to the brain, and the patient died 15 months post-operatively.\nOUTPUT:" }, { "from": "agent", "value": "Metastatic Renal Cell Carcinoma" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 20-month-old previously healthy female was brought into the emergency department because of acute onset of altered mental status. The mother had noted that the patient also had episodes of flexion and extension of her upper extremities. The patient was then observed in emergency department to have tonic clonic seizure activity, which was responsive to lorazepam. The patient was febrile at 104.5 F and tachycardic at 160 bpm and had a blood pressure of 111/76 and breathing 25 breaths/minute with an oxygen saturation of 100% on RA. The patient was noted to be lethargic, with pupils that were 2 mm in size, sluggishly reactive, bilaterally. Neurologically, the patient was observed to have decreased tone, midline gaze, and no facial asymmetry. She was not responsive to noxious stimuli. Deep tendon reflexes were noted to be 3+ bilaterally in the upper and lower extremities. Patient initial blood work was notable for hypokalemia (2.6 meq/L), metabolic acidosis, and elevated lactate of 6 mmol/L. The patient continued to have focal seizures not controlled by lorazepam. The patient was subsequently admitted to the pediatric intensive care unit (PICU). An extensive workup was undertaken. The patient was empirically treated for severe infection. Her workup was notable for negative blood cultures, cerebral spinal fluid analysis, and negative computed tomography scan of the head and normal chest X-ray. A CBZ level was sent by the primary team and noted to be elevated to 29 mcg/ml. Multidose activated charcoal (MDAC) was started. Two days after MDAC was started, the patient's repeat CBZ levels were 20, 11, and <2 mcg/ml. The patient was extubated after, with no further episodes of seizure activity. The patient had no residual neurologic deficient and was eventually discharged home.\nOUTPUT:" }, { "from": "agent", "value": "Carbamazepine Toxicity" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 41-year-old Nigerian man with no significant past medical history presented with chief complaints of jaundice, nausea, fatigue, and unintentional weight loss over 2 months. He reported rare alcohol use and denied illicit drug use or a family history of liver disease. He had no history of use of herbal medications and did not have a history of obesity. Physical examination was unremarkable except for scleral icterus. Laboratory evaluation revealed elevated aspartate transaminase 315 U/L, alanine transaminase 358 U/L, alkaline phosphatase 144 U/L, total bilirubin 5.6 mg/dL, and direct bilirubin 2.9 mg/dL. Abdominal ultrasound and computed tomography revealed findings consistent with liver cirrhosis without any evidence of ascites or a focal liver lesion. Ceruloplasmin, alpha 1 antitrypsin, and alpha-fetoprotein were within normal range. Antismooth muscle (ASMA), antimitochondrial, antiactin, and liver-kidney microsomal antibodies (anti-LKM) were negative, but serum immunoglobulin G (IgG) was notably elevated (19 g/dL) and this raised concern for AIH as the cause of CLD. Iron profile was obtained, and this caused a diagnostic challenge as it revealed markedly elevated serum ferritin of 1349 ng/mL and transferrin saturation of 56%, leading to suspicion of an iron overload syndrome as the cause of CLD. He had no history of receiving blood products or iron supplementation, and he denied a family history of hemochromatosis. Hemoglobin A1c was within normal limits, and he denied long-term joint pain, erectile dysfunction, or symptoms of heart failure. Given the diagnostic dilemma between AIH and hemochromatosis:as suggested by high serum IgG and concomitant elevation of ferritin and transferrin saturation, respectively, a liver biopsy was performed for definitive diagnosis. Perls' Prussian blue staining was negative, effectively excluding iron overload as the cause of CLD (Figure 2). The patient was started on oral prednisolone for the treatment of AIH, and there was an improvement in clinical and laboratory parameters on follow-up.\nOUTPUT:" }, { "from": "agent", "value": "Autoimmune Hepatitis" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 61-year-old woman was referred one month after primary total knee arthroplasty from a Rehabilitation Clinic to an Orthopaedic and Trauma Surgery Department of a Tertiary Care University Hospital for a presumed periprosthetic joint infection (Fig. 1). On admission, white blood cell count was normal, C-reactive protein was elevated (167 mg/dl), phosphate was reduced (0.32 mmol/l) and calcium was normal (2.36 mmol/l). The patient's comorbidities included metabolic syndrome with type 2 diabetes mellitus accompanied by micro- and macrovascular complications. Chronic kidney disease was classified stage \"G5\" (kidney failure, GFR 9 mL/min, KDIGO) without haemodialysis. Endoprosthesis explantation and implantation of a static bone cement spacer was performed and vacuum assisted closure-therapy (VAC-therapy) was applied for a prepatellar soft tissue defect. Multiple intraoperative tissue cultures grew Enterobacter cloacae complex. Piperacillin/tazobactam was administered according to antibiogram. Multiple VAC exchanges were performed for soft tissue conditioning. Satisfactory wound healing failed to occur despite of sterile tissue samples. A gastrocnemius muscular flap was applied for ongoing impaired wound healing despite consistently sterile tissue cultures. Unfortunately, flap necrosis developed after 8 days (Fig. 2A) and additional necrotic lesions occurred on the contralateral lower extremity after 15 days. A skin biopsy revealed fatty tissue necrosis with extensive interstitial calcification on histopathology. Parathyroid hormone (PTH) levels were elevated at 441 pg/mL (normal range, 11-67 pg/ml). Haemodialysis, which had been started upon worsening of renal function, was thus intensified and pharmacological parathyroid suppression was initiated by thiosulfate and cinacalcet administration. Due to persistently high PTH levels, parathyroidectomy was performed and PTH levels normalized subsequently.\nOUTPUT:" }, { "from": "agent", "value": "Calciphylaxis" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 65-year-old female, with a history of nyctalopia presented with a sudden, profound, and painful loss of vision OU of three days duration. She recounted a history of poor vision OU since 20 years. On examination, her visual acuity (VA) was hand movement (HM) OU. There was circumciliary congestion (CCC) with corneal edema (Figure 1). The anterior chambers were shallow with Van Herrick (VH) grade two. The pupil was middilated and sluggishly reacting to light OS and presence of posterior subcapsular cataract (PSCC) OU. Goldmann applanation tonometry (GAT) revealed an intraocular pressure (IOP) of 24 mmHg OD and 58 mmHg OS. She was managed with full tolerated antiglaucoma medications (Tab acetazolamide 250 mg, Gtt pilocarpine nitrate 2%, Gtt timolol maleate 0.5%+Gtt brimonidine tartrate 0.1%, and Gtt latanoprost 0.005%) and topical steroids (Gtt prednisolone acetate 1%). The following day, the corneal clarity was enhanced and her IOP was within a normal range of 11 mmHg OD and 12 mmHg OS, respectively. Gonioscopic examination disclosed closed angles in superior, temporal, and nasal quadrants OD, whereas, there was peripheral anterior synechiae (PAS) in all quadrant OS. Fundus examination revealed the cup disc ratio (CDR) 0.5 OD and 0.9 OS. The peripheral vessels were narrow and attenuated OU. There was diffuse RPE atrophy and bony spicules in the posterior pole and midperipheral retina (Figure 2). Neodymium yttrium aluminium garnett (Nd: YAG) laser peripheral iridotomy (LPI) was done OU followed by phacoemulsification with posterior chamber intraocular lens (PCIOL) OD. Her postoperative best corrected visual acuity (BCVA) was 4/60 OD, and IOP was regulated under control OU with topical medications and hence continued.\nOUTPUT:" }, { "from": "agent", "value": "Angle Closure Glaucoma, Retinitis Pigmentosa" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 60-year-old woman with disturbed consciousness was admitted by ambulance. Her Glasgow Coma Scale was 14 (E4V4M6). She had no treatment history of endocrinological diseases. Head computed tomography without contrast material revealed dilated lateral ventricles without third or fourth ventricle dilatation. Significantly high-density lesions smoothly extended from the choroid plexus of the lateral ventricles to the third ventricle and occupied both sides of the FOM [Figure 1a and b]. Magnetic resonance imaging showed that the choroid plexuses were modestly enhanced with gadolinium, but there was no obvious tumoral lump, which indistinguishable from the contiguous choroid plexus [Figure 1c]. The diagnostic endoscopic biopsy was performed using a flexible neuroendoscopic system (EVIS LUCERA SPECTRUM Video Imaging System, Olympus, Tokyo) via the left lateral ventricle. Egg shell-like entirely calcified lesions that smoothly extended toward the FOM were detected [Figure 2a and b]. The contralateral FOM was inspected through the spontaneously perforated septum pellucidum and was also found to be occluded by the calcified lesions. Most of these calcified lesions were too hard to resect; therefore, a biopsy was performed to obtain a small specimen from relatively less calcified lesions near the FOM. Resection was not selected because the calcified lesions had tightly adhered to the veins and fornix; therefore, the patient underwent ventriculo-peritoneal shunting via the same tract [Figure 1d]. A histological examination of the specimen revealed a number of psammoma bodies with round and spindle tumor cells [Figure 3a]. Mitosis was scarcely observed, and the immunohistochemical staining index for Ki-67 was <1% [Figure 3b]. She was alert and conscious postoperatively and was subsequently discharged 10 days after surgery.\nOUTPUT:" }, { "from": "agent", "value": "Psammomatous meningiomas (WHO Grade I)" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: The patient was an 8-month-old female infant with left DDH. She had been diagnosed with dislocation of the left hip at another hospital at the age of 3 months, and she was treated with a Pavlik harness for 4 weeks. However, her left hip was not reduced, and she was admitted to our institution at the age of 8 months. The anteroposterior radiograph showed that the left femoral head was completely dislocated and had shifted to the lateral and proximal side (Figure 1). She did not have the abnormality at the time of birth; in addition, no past illness, allergy, or family history of DDH were noted. At our institution, she underwent closed reduction under general anesthesia. Her hip joint was reduced; however, it was unstable, and the femoral head was easily dislocated when we decreased the hip abduction angle down to 60 . Subsequently, arthrography was performed to verify the reduction and to analyze the obstructive factors and afferent nature of the femoral head. First, the legs were maintained in the frog-leg position, and then, a 23-gauge Cathelin needle was inserted in the central part of the femoral proximal epiphyseal line using the anterior approach. The anesthesiologist noticed the change, and he increased oxygenation from 33% oxygen to 100% under observation. The blood oxygen concentration and ETCO2 concentration gradually improved and returned to normal values after 2 min and 12 min, respectively. Other vital signs such as blood pressure and pulse rate remained unchanged. An arthrogram showed good reduction of the femoral head. Plaster cast fixation was performed at an abduction angle of approximately 70 . After the operation, she was placed in a plaster cast, abduction brace, and Pavlik harness, for 4 weeks each. At the latest examination performed at the age of 4 years, the patient had not experienced any recurrence of dislocation.\nOUTPUT:" }, { "from": "agent", "value": "Air Embolism, Developmental Dysplasia of the Hip" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: 0A 38-year-old Asian male presented with \"sudden onset of worst headache of my life\" that was generalized in nature and not associated with nausea, vomiting, or seizures. His past history was unremarkable. He was initially treated for sinusitis and prescribed a course of antibiotics and nasal decongestants, which initially improved his symptoms. After approximately one month, the patient's headache reoccurred and persisted. Later careful history analysis revealed that his headache was worst when standing or sitting, but relieved when lying down. Other causes of headache were ruled out. On examination, all vital signs were within normal limits. There was no neck stiffness and no rash. Systemic examination was unremarkable. On neurological evaluation, patient was alert, oriented with intact higher cognitive function including speech. Cranial nerves including fundus exam, motor, sensory, and cerebellar examination demonstrated nonfocal neurological exam and no abnormality detected. Considering the patient's age, symptoms, unremarkable past medical problems, nonfocal exam, and radiological findings prompted us to consider SIH as the diagnosis and magnetic resonance imaging (MRI) brain was ordered to confirm it. MRI myelography showed epidural fluid at the C2-C4 level with possible dural tear at C2 on right side and C3, C4 on the right side. Epidural fluid was also seen in the entire dorsal region and in the upper lumbar region without any obvious dural tear. The patient was scheduled for an epidural patch, which was performed at the cervical level using 12 cc of autologous blood. Symptoms resolved significantly after the epidural blood patch. Repeat CT head 3 months postblood patch showed resolution of the subdural fluid collection [Figure 3]. Patient is asymptomatic till date.\nOUTPUT:" }, { "from": "agent", "value": "Bilateral subdural hematoma, Spontaneous Intracranial Hypotension (SIH)" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: The patient's general condition improved and he was extubated and discharged after ending the tube thoracostomy. The tube thoracostomy was repeated. After performing negative aspiration and talc pleurodesis twice, the patient's drainage ended on day 14. The patient was readmitted 15 days later due to shortness of breath. Surgery was considered, but was contraindicated by the patient's advanced age and comorbidities (cardiac failure and severe COPD). Based on a published report, radiotherapy treatment was attempted. Ventilation scintigraphy showed findings consistent with the refractory air leak in the right upper lobe (Figure 3). Local radiotherapy at 10 Gy was applied to a 10 x 10 cm area determined using ventilation scintigraphy with a 3 cm margin, twice, 1 week apart. A followup chest X-ray showed complete expansion of the lung and no air leak. The tube thoracostomy was ended.\nOUTPUT:" }, { "from": "agent", "value": "Pneumothorax, Chronic Obstructive Pulmonary Disease (COPD)" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 46-year-old woman was scheduled for elective hand surgery. Her medical history was significant for bipolar disorder, chronically treated with oral lithium carbonate 750 mg/day during the 4 years prior to the surgery. Blood lithium levels 2 days prior to the surgery were 0.45 mEq/L (therapeutic values usually considered are between 0.6 and 1.2 mEq/L). She had had no previous surgery, except minor dental procedures under local anesthesia, and no known allergies. Due to patient preference for regional anesthesia, an infraclavicular block was performed under ultrasound guidance using a 22 G stimulating needle (Polymedic ; te me na SAS, Carrieres-sur-Seine, France). Each one of the three cords of the brachial plexus was separately visualized using an in-plane short axis approach and concomitantly electrically stimulated by nerve stimulator, after which a local anesthetic \"cuff \" was injected individually around each cord, using 10 mL of plain bupivacaine 0.25% (Kamada, Beit-Kama, Israel) and lidocaine 1.5% (Rafa Laboratories Ltd, Jerusalem, Israel) solution (0.1 mg/kg and 0.075 mg/kg, respectively, totaling 30 mL). Neither paresthesia nor pain was elicited during the injection. Sensory block was evaluated using pinprick and was satisfactory 12 minutes following the injection. No adverse effects were observed. In the ward, the patient complained of residual intense block, both motor and sensory, which persisted for approximately 20 hours and wore off slowly until it was absent 42 hours following the injection of the local anesthetic solution. Follow-up at 1 week and 1 month revealed no motor or sensory deficit, no paresthesia, and no sign of nerve damage. No ethical issues arose from the medical management of this case.\nOUTPUT:" }, { "from": "agent", "value": "Prolonged nerve blockade" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A term female was born at 39 weeks of gestation to a 32-year-old G2P1 by spontaneous vaginal delivery. Apgar scores were 9 and 9 at 1 and 5 minutes, respectively. The pregnancy was uncomplicated. Physical examination revealed a weight of 3650 gm (70th centile), length of 51 cm (60th centile), and head circumference of 33 cm (15th centile). Karyotype was obtained on the first day of life. Recurrent vomiting after each feeding was noted since birth. A plain abdominal radiograph showed a nonspecific bowel gas pattern with gas noted in the stomach, duodenum, and distal bowel (Figure 1). An upper gastrointestinal (UGI) series showed a complete obstruction to the flow of barium at the proximal portion of the duodenum. The contrast was also seen in the proximal jejunum which was located in the right upper quadrant (Figures 2 and 3). The patient underwent exploratory laparotomy on the 3rd day of life. The postoperative course was uneventful, and the infant was discharged home at 35 days of life.\nOUTPUT:" }, { "from": "agent", "value": "Down syndrome, Duodenal atresia, Malrotation" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 21-year-old female with history significant for ventriculoperitoneal shunt-dependent hydrocephalus since infancy for myelomeningocele presented to our Emergency Department with an 8-day history of mild nausea and fevers up to 39 C. The patient had no history of shunt failure or revisions. She noted no neurological signs or symptoms, nor did she complain of a headache. The physical examination revealed a firm, nontender mass in the lower right abdominal quadrant. CT of head showed unremarkable ventricle size, good proximal shunt catheter placement, and no transependymal flow, although no previous imaging was available for comparison. An abdominal ultrasound was interpreted as a multiseptated fluid collection within the right lower quadrant extending into the lower abdomen, distinct from bowel, ovary, and uterus. A small portion of the shunt catheter was reported to be within this fluid collection; however; the tip could not be identified (Figure 1(a)-1(c)). As the patient had a history of a ventriculoperitoneal shunt with new onset of a cystic abdominal mass, the patient was diagnosed with a cerebrospinal fluid (CSF) pseudocyst, and the neurosurgical service was consulted. Because the tubing could not be localized within the mass, and the patient's history was not entirely consistent with a CSF pseudocyst (abdominal pain and distension, headaches, neurological deterioration), the neurosurgical service requested an abdominal CT. This study revealed a complex, multiseptated 16 x 8 x 17 cm pelvic mass emanating from the right ovary. The distal shunt tubing appeared to be draped circumferentially around the lesion and was not contained within the mass itself, as is generally the case with a CSF pseudocyst (Figure 1(d)-1(f)). This unexpected finding indicated that the shunt was independent of the lesion, and lead to an exhaustive differential diagnosis demonstrated in (Table 1).\nOUTPUT:" }, { "from": "agent", "value": "Ovarian Teratoma" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 65-year-old woman, a phototype VI of Fitzpatrick's classification, consulted in dermatology for multiple ulcerative and cauliflower tumors of the neck. The time from onset of tumors to consultation was two years. The initial lesion was a tumor in the left cervical region which became ulcerated, followed two months later by the occurrence of two other tumors on the left and right side of the neck. The patient had received treatment with antibiotics, antiseptics, and traditional herbal poultices without success. Topical hydroquinone and highly potent corticosteroids such as clobetasol propionate were the main products used on the whole body and the face for a duration of 30 years. There is no personal or family history of cancer. The patient was obese (BMI = 38.3 kg/m2) and was known to be hypertensive. On examination, there were three painful, bleeding on contact, left latero-cervical ulcerative tumors with an infiltrated base measuring 6 x 5 cm, 3 x 3 cm, and 8 x 2 cm, respectively (Figure 1), and an ulcerative tumor measuring 4 x 3 cm on the right latero-cervical side (Figure 2). Angiomatous nodular lesions were also present in the vicinity of these tumors and on the anterior aspect of the neck. The rest of the skin examination showed exogenous ochronosis of the neck and face, and diffuse skin atrophy with local ecchymotic patches and stretch marks on the whole body. There were no associated palpable lymph nodes. The rest of the clinical examination was normal. Blood tests for viral hepatitis and human immunodeficiency virus (HIV) were negative. The cervical, thoracic, abdominal, and pelvic TDM revealed pulmonary metastases. The patient underwent a complete surgical removal of the right latero-cervical tumor. The left latero-cervical tumors were not removed because they infiltrated the large vessels. Chemotherapy before surgery was prescribed but not honored for financial reasons. The patient died 2 months after her first consultation in respiratory distress.\nOUTPUT:" }, { "from": "agent", "value": "Multiple Squamous Cell Carcinoma" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 78-year-old man with a one-year history of lenalidomide therapy for multiple myeloma presented to an outpatient dermatology clinic with a two-day history of a painful rash on his hands, as well as red, painful eyes. He denied any recent upper respiratory infection or having started any new medications. At the clinic visit, physical examination was notable for scattered pink dermal papules with a dusky red center bilateral dorsal and palmar hands, as well as bilateral conjunctival erythema (Figure 1). Differential diagnoses included erythema multiforme, acute febrile neutrophilic dermatosis, erythema elevatum diutinum, and multicentric reticulohistiocytosis. A punch biopsy was taken from the left index finger. Histological examination revealed a dense perivascular and interstitial inflammatory infiltrate composed of lymphocytes, histiocytes, and numerous neutrophils with surrounding papillary dermal edema. High-power views demonstrated scattered nuclear dust and fibrin within the walls of the small blood vessels with extravasation of red blood cells in the surrounding stroma (Figure 2). Upon discussion with the patient's oncologist, it became known that the patient had received an MMR vaccine two weeks prior to the rash. The patient did not have a history of COVID-19 vaccination. The patient followed up one week later with a more typical appearing rash for LCV (Figure 3). The rash was resolved with the use of topical clobetasol ointment and his eyes were also cleared. The patient has continued to receive lenalidomide without any recurrence of the rash.\nOUTPUT:" }, { "from": "agent", "value": "Leukocytoclastic Vasculitis, Conjunctivitis" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A thirty-year-old male was undergoing evaluation of chronic left flank pain and intermittent fever. His ultrasonography (USG) revealed the enlarged left kidney with gross hydronephrosis and staghorn calculus. The serum creatinine value was 1.1 mg% (normal 0.7-1.2 mg%). His blood examination had revealed leukocytosis and urine examination had showed 10-15 pus cells/hpf. He underwent dynamic renal scintigraphy for evaluation of hydronephrosis of left kidney detected on USG. The scintigraphy was performed with intravenous (IV) injection of 375 MBq of Tc-99m diethylenetriaminepentaacetic acid and F-0 injection of furosemide in the dose of 1 mg/kg. The dynamic imaging during perfusion phase revealed transit of bolus through aorta [red arrow, Figure 1], vascular blush to right kidney (blue arrow), and an intense vascular blush in region of left renal fossa at level of lower pole of kidney (black arrow). The uptake phase of renal scintigraphy revealed the absence of cortical uptake in left kidney and normal tracer uptake of right kidney [Figure 2]. To evaluate cause of vascular blush in left renal fossa, further evaluation with contrast-enhanced computed tomography (CECT) was performed. CECT was performed on a 64 slice scanner (Philips Brilliance) before and after IV injection of noniodinated contrast medium (iohexol 350). Figure 3a precontrast coronal section shows large left renal staghorn calculus with enlarged, hydronephrotic kidney. Figure 3c reveals arterial phase of CECT, depicting enhancement in the lower pole of the left kidney. Figure 3b shows axial section images of postcontrast delayed phase at the level of lower pole. Persistent parenchymal enhancement, perinephric fat stranding, and thickening of Gerota's fascia was seen (arrows). Figure 3d sagittal CECT section shows that the perinephric fat stranding is extending inferoposterior to the lower pole of left kidney. The postnephrectomy specimen revealed gross hydronephrotic left kidney with APN involving a lower pole.\nOUTPUT:" }, { "from": "agent", "value": "Acute pyelonephritis" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 36-year-old gravida 2, para 2 female with a 2-month history of pelvic pain and menstrual dysregulation was referred to our hospital for an investigation of her symptoms. Her medical history revealed no abnormalities. In physical examination, she felt tenderness in her left lower quadrant. Transvaginal ultrasound imaging revealed a 5 cm left ovarian cystic mass. Magnetic resonance imaging of the abdomen with contrast media detected a 5 cm left ovarian cystic mass with papillary projections. Laboratory test results for cancer biomarkers were as follows; CA-125:311 U/ml (normal range <35 U/ml); CA-19-9:1100 U/ml (normal values <37 U/ml); CEA: 2.5 ng/ml (normal values <3 ng/ml); and CA-15.3:31.1 U/ml (normal values <35 U/ml). Due to suspicion of malignancy, gastroscopy and colonoscopy were performed which revealed no abnormalities. The patient's smear and endometrial biopsy results were also negative. The patient was scheduled for an operation. We performed an exploratory laparotomy with frozen section consultation by a pathologist experienced in gynecologic oncology. We sent left salphingoopherectomy material for the frozen section. A total abdominal hysterectomy and bilateral salphingoopherectomy with pelvic-paraaortic lymph node dissection was performed. 1A). Our findings showed that the two veins lied parallel to each other throughout their length. We did not find any abnormalities on the right side.\nOUTPUT:" }, { "from": "agent", "value": "Epithelial ovarian cancer, Complete duplication of left external iliac vein" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: This is a 12-year-old girl who presented with new left chest bulge, nausea, and emesis. The patient had a history of staring spells and grand mal seizures for which she was treated with VNS, with resolution of her seizures. Per the mother of the patient, the family was on a long road trip when the child was noted to be progressively more tired and nauseated with emesis. The mother then noticed an enlarged area on the patient's left chest which she believed to be secondary to migration of the VNS battery. Further, the mother stated that the patient had several seizure episodes on this road trip though she had not had a seizure in years since the VNS was placed. On physical examination, the child was lethargic but alert, following commands, and full strength but visibly nauseated. The child complained of headache, nausea, but denied blurry vision. A chest x-ray (Fig. 1, Fig. 3) was initially performed in the emergency room due to the chief complaint of the mother being new left chest bulge. Next, a computed tomography (CT) of the head without contrast and a shunt series consisting of anterior/posterior (AP) and lateral skull x-rays and abdominal x-rays were ordered. 3). The skull x-rays did not show any signs of catheter disconnection or fracturing and the abdominal x-ray did not show retained catheter fragments.\nOUTPUT:" }, { "from": "agent", "value": "Coiling of distal shunt catheter into subcutaneous pocket, Hydrocephalus" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 48-year-old male, with no past medical history, presented to ED with fullness and Tenderness at the left gluteal wound that patient obtained from gunshot 18 days ago. 1), but the bleeding eventually stopped with compression and patient was discharged. On this return, patient reported that he had one episode of bleeding from the wound a week after discharge, which again stopped after compression. Physical examination demonstrated a well healing bullet wound with palpable fullness and mild tenderness to palpation but no evidence of bleeding, discharge or erythema. 2), with a size of 1.4 cm x 2.2 cm and an underlying stable hematoma. Patient also complained of intermittent subjective fever and new onset of shortness of breath at the time. Lower extremity venous duplex showed no evidence of deep venous thrombosis in the bilateral lower extremities. However, given the close proximity of the gunshot wound tract to the pelvic veins, it is possible that the blast effect from the bullet caused a pelvic DVT, which is difficult to detect on ultrasound or CT scan. The patient initially underwent angiogram (Fig. 3). Subsequently, coil embolization was performed at the pseudoaneurysm. Post-embolization angiogram confirmed proper placement of the coil without extravasation (Fig. 4). During the admission, there was no expansion of hematoma or bleeding from serial monitoring of the gunshot wound despite anticoagulation therapy, and patient was safely discharged with oral anticoagulation medication.\nOUTPUT:" }, { "from": "agent", "value": "Superior gluteal artery pseudoaneurysm, Pulmonary embolism" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 28-year-old housewife admitted with reddish tender lesions all over the body of 2-day duration. There was no associated fever or other systemic complaints except for severe body pain and pain over the lesions. There was no history of prolonged sun exposure or drug intake prior to onset of lesions. There was history of four similar episodes in 9 months with admission in different hospitals each time and dropping out half way while on treatment. On examination, lesions were reddish brown macules all of similar size and morphology all over the body predominantly over thighs and legs with fewer lesions on chest, abdomen, face, and total sparing back of trunk [Figures 1-3]. On scrubbing with alcohol, some lesions showed fading of color. Nothing significant was detected from routine blood and urine examination and skin biopsy. Patient was treated with only placebos. Condition was not revealed to patient or relatives and no such history was probed to find out nature of infliction of lesions as same would lead to patient hopping. No new lesions appeared and all lesions started fading in about a week. Later, detailed psychiatric evaluation was done, according to which patient did not have any perceptual abnormalities. Psychiatric evaluation could not elicit any external incentive for act like fear, avoiding duties, or financial gain. Both patient and bystanders gave inconsistent history. Since the past nine months, patient is being admitted in different hospitals four times, each time developing lesions suddenly. All the episodes occurred when the husband was away from home. She would get admitted to hospital and while the investigations are being done, abscond from hospital once the false nature has been identified. Skin lesions cleared completely in 2 weeks. Patient is under regular psychiatric follow-up with no new episodes since past six months.\nOUTPUT:" }, { "from": "agent", "value": "Munchausen syndrome, dermatitis simulata" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: Few asymptomatic periorbital lesions had developed for the last few years. The first clinical impression was xanthelasma and granuloma annulare. Initial excisional biopsy was performed and diagnosed as subcutaneous granuloma annulare. Other investigations were done and showed hypercholesterolemia that was effectively controlled by lipidlowering agents. Some lesions were treated with intralesional and topical corticosteroids without any clinical improvement. The lesions located on her both forearms, legs, and periorbital regions have progressively enlarged. Later on, the patient was referred to our hospital for dermatologic consultation. Physical examination showed multiple yellowish to reddish-brown nodules and plaques on face and extremities (Figures 1(a) and 1(b)). Some lesions were observed to have central ulceration and atrophy distributed on her legs and forearms (Figure 1(c)), healing with scar. When NXG was diagnosed, other investigations for underlying hematologic malignancies were performed. Serum protein electrophoresis demonstrated monoclonal spike in gammaglobulin region, suggesting monoclonal gammopathy. Immunoelectrophoresis also showed IgG lambda monoclonal gammopathy. There was no osteolytic lesion in bone survey. Intralesional corticosteroids have been employed to treat cutaneous lesions with mild clinical improvement.\nOUTPUT:" }, { "from": "agent", "value": "Necrobiotic Xanthogranuloma, Asymptomatic Multiple Myeloma" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: There was no further neurovascular deficit. His shoulder was reduced under sedation in the ED, with post-reduction radiographs reviewed and accepted as demonstrating a successful joint reduction (Figure 2). Given the deemed satisfactory appearance of the shoulder, the patient was referred routinely through our virtual fracture clinic pathway. He was subsequently reviewed in our Upper Limb trauma service, where a computerized tomography (CT) scan was arranged (Figure 3 and Figure 4). This confirmed significant posterior displacement of his greater tuberosity. This displacement was present on the post-reduction plain radiograph but was not recognized. As a result of identifying the displacement, surgical fixation with a locking plate and suture construct was undertaken through a deltoid-splitting approach, seven days following presentation to the ED (Figure 5). The sutures used were size 2 FiberWire sutures, and they were passed through the k-wire holes of the plate. We decided to use this approach to the fracture as it gives us greater access to posteriorly displaced greater tuberosity fragments and allows for better reduction and fixation, regardless of the chosen mode of fixation. On this occasion, we selected sutures as the primary mode of fixation and augmented the construct with a plate in buttress mode, as the fragment was sizeable and not significantly comminuted. Post-operative radiographs taken at that time demonstrated a satisfactory and anatomical position and alignment of the greater tuberosity fragment (Figure 6).\nOUTPUT:" }, { "from": "agent", "value": "Proximal Humerus Fracture/Dislocation, Axillary nerve injury" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: Recently, the lesion was rapidly increasing in size and subsequently ulcerated [Figure 1]. The lesion was very firm with a hard texture to touch. He also complained of local pain. Incisional biopsy was taken from the non ulcerated area and material was sent for histopathological examination. Microscopical examinations revealed diffuse non epidermotropic infiltrares predominantly made up of large non cleaved cells with variable proportions of centroblasts and immunoblast-like cells. The cells have large nuclei with conspicuous nucleoli. The tumor cells were located in the papillary and reticular dermis and reaching the interface between dermis and subcutis [Figure 2]. No epidermotropism was evident and epithelial cells of epidermis were unremarkable. Immunohistochemistry (IHC) revealed expression of CD20, CD19, Bcl-2, Bcl- 6 and MUM-1 by tumor cells, while they were negative for CD10, CD30, EMA, CD3, and CD5 [Figures 3 and 4]. Proliferative index (Mib 1) was 30%. Based on the clinical, histopathologic, and the IHC examination, a diagnosis of PCLBCL-LT was established. Radiologic examination, peripheral blood smear examination, and bone marrow did not reveal any abnormality and/or involvement by lymphoma. Patient was treated with Rituximab, cyclophosphomide, doxorubicin, oncovin, and prednisone (R-CHOP). Local radiotherapy / involved field radiotherapy (IFRT) was also given. However, after 3 months the patient came back with central nervous system/brain involvement and paraparesis. Despite the treatment, the patient died within 1 month.\nOUTPUT:" }, { "from": "agent", "value": "Primary cutaneous large B-cell lymphoma, leg type" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: In addition, she had a history of multinodular goiter. By physical examination, it was also apparent that she had a relatively large head in relation to her length (length 170 cm and head circumference 61 cm, i.e., above 97th percentile). According to the patient, macrocephaly is a common feature in her family. Finally, her sister's mammography (mediolateral oblique direction shown) showed massive calcifications in multiple, well-defined masses, some of them with adipose tissue, diagnostic of hamartomas. The mutation was inherited from the patient's mother. The patient was treated with neoadjuvant chemotherapy with a partial response, followed by a modified radical mastectomy and preventive contralateral mastectomy, and by locoregional radiotherapy (because of 5 positive axillary lymph nodes) plus adjuvant endocrine therapy.\nOUTPUT:" }, { "from": "agent", "value": "Breast Cancer, Cowden Syndrome" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 71-year-old Japanese male visited our outpatient clinic with a 6-month history of a rapidly growing red plaque on his back. On his initial visit, physical examination revealed a red, pigmented plaque, 90 x 80 mm, with a dome-shaped elastic-soft nodule (fig. 1a). The diameter of the nodule was approximately 20 mm. A skin biopsy from the edge of the plaque revealed atypical squamous cells containing large oval nuclei with occasional conspicuous nucleoli, with individual keratinization, mitotic figures and clumping cells. In addition, the biopsy specimen from the center of the nodule revealed dense infiltrating atypical squamous cells throughout the dermis (fig. 1c). We first diagnosed this patient as invasive BD and excised the tumor with a 5-mm margin. Unexpectedly the histological finding of the whole tumor revealed that the squamous cell-composed tumor was surrounded by another type of tumor composed of small round cells with scant cytoplasm and oval nuclei (fig. 1b, d). These small round cells were positive for AE1/AE3, cytokeratin 20, synaptophysin and CD56, and negative for 34betaE12, cytokeratin 7, chromogranin A and TTF1. From the above findings, we diagnosed this tumor as MCC concomitant with invasive BD. We screened for a possible internal malignancy with positron emission tomography computed tomography and found no evidence of metastasis. As we and other reports suggested, both invasive BD and MCC contain substantial numbers of immunoreactive and immunosuppressive cells. Notably, a previous report even suggested that the number of tumor-infiltrating CD8+ cells determines the prognosis of MCC. Therefore, we further employed immunohistochemical staining for CD8 (fig. 2a, b), caspase 3 (fig. 2c, d), Foxp3 (fig. 3a, b), CD163 (fig. 3c, d) and CD206 (fig. 3e, f) in the lesional areas of invasive BD and MCC. Substantial numbers of immunoreactive and immunosuppressive cells were detected at the edge of the tumor in invasive BD, whereas TILs were scattered at the center of the tumor in MCC. Both invasive BD and MCC contained caspase 3-expressing cells in the CD8-infiltrated areas, which suggested induction of an anti-tumor immune response in the tumor microenvironment by CD8+ cytotoxic T cells.\nOUTPUT:" }, { "from": "agent", "value": "Merkel Cell Carcinoma, Invasive Bowen's Disease" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: In June 2016, a non-smoking 70-year-old woman with ulcerative colitis was referred to our hospital after a nodular shadow was noted on right-side chest X-ray. Her Eastern Cooperative Oncology Group performance status was 0. The levels of tumor markers, including carcinoembryonic antigen, cytokeratin 19 fragment, and pro-gastrin-releasing peptide, were normal. Chest computed tomography (CT) revealed a 2.3-cm pulmonary mass in the right upper lobe (Fig. 1). Brain magnetic resonance imaging (MRI) revealed a 1-cm right-sided frontal lobe tumor (Fig. 2). The Roche cobas(R) EGFR Mutation Test v2 (Roche Molecular Systems, South Branchburg, USA) confirmed the concurrent exon 19 deletion mutation and exon 20 insertion mutation (detectable EGFR exon 20 insertion gene mutations: V769_D770insASV, D770_N771insG, D770_N771insSVD, H773_V774insH). After stereotactic radiotherapy for the brain metastasis, treatment with afatinib was initiated (40 mg/day) at the beginning of August 2016. After 20 days, afatinib was reduced to 30 mg/day because her stool had been bloody for 2 days. 3). Brain MRI did not reveal any other metastases, and PET/CT showed no abnormal findings in September 2017, indicating a complete response (CR) following treatment with afatinib.\nOUTPUT:" }, { "from": "agent", "value": "Lung Adenocarcinoma" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: Case B is a 19-year-old male and the younger brother of the patient described in case A. He improved on oral and topical mesalamine. In the subsequent year his symptoms recurred, and an increased dose of oral mesalamines, mesalamine enemas, and short courses of corticosteroids resulted in temporary clinical improvement only. Endoscopically, his proctitis progressed to left-sided UC and he was admitted to our IBD service. Intravenous administration of methylprednisolone was initiated with only minimal clinical improvement by day 5. Subsequently, he received a loading dose of infliximab 5 mg/kg in order to induce remission. He noticed improvement of symptoms and was discharged. However, he shortly had recurrence of his symptoms and, despite escalation of the infliximab to 10 mg/kg and addition of hydrocortisone enemas, was unable to achieve symptom control. Infliximab was discontinued because of the absence of clinical benefit. His TMPT was determined at 19.7 U/ml RBC and MP was initiated at approximately 1.5 mg/kg. Within a few weeks after initiation of this thiopurine therapy, his symptoms continued and we noticed elevation of his ALT to 141 U/l. The MP metabolites were determined and showed a 6-TGN level of 301 and elevated 6-MMP levels (12,796 pmol/8 x 108 RBC). Subsequently, the dose of MP was reduced to 25 mg and allopurinol 100 mg per day was started. He promptly responded to allopurinol with shunting of his thiopurine metabolites toward the formation of 6-TGN (351 pmol/8 x 108 RBC) and undetectable 6-MMP levels, which clinically corresponded with complete resolution of his transaminitis. He rapidly achieved stable remission with this strategy. We continue to follow him and he has currently been in stable remission for 8 months, maintained by MP 50 mg and allopurinol 100 mg per day.\nOUTPUT:" }, { "from": "agent", "value": "Ulcerative colitis" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 96-year-old man presented to A&E unwell. His past medical history was significant for frailty, COPD, ischemic heart disease and multiple vascular operations including a right axillofemoral bypass graft for occlusion of a previous aorto-uni-iliac stent. On admission, he was septic with a temperature of 38.6 C, heart rate of 118 bpm and a blood pressure of 179/80 mmHg. The axillofemoral bypass graft was found to transgress the right lateral chest wall with 10 cm of the graft externalized and exposed (Fig. 1). Purulent discharge and erythema surrounded the site. On further questioning, the graft had eroded through the skin several years prior with no surgical advice sought. Both feet were warm and well perfused. Femoral pulses only were palpable. His inflammatory markers were markedly elevated with a white cell count of 21 7 x 109/L and CRP of 181 4 mg/L. Proteus mirabils and coagulase-negative staphylococcus were cultured from the blood. A duplex ultrasound confirmed the axillofemoral graft's patency. CT angiography of the aorta additionally demonstrated no significant graft enhancement within the body (Fig. 2). He was commenced on intravenous Pipercillin/Tazobactam as per microbiological culture sensitivities. In view of the patient's comorbidities and high anesthetic risk, surgery was performed under local anesthesia. The axillofemoral graft was test-clamped for 30 min following heparinization (5000 units). The leg was seen to remain viable allowing for the graft to be explanted without the need for further revascularization. The patient made an uncomplicated recovery with the leg remaining neurovascularly intact. He was discharged home on postoperative day 9 on a prolonged course of oral antibiotics.\nOUTPUT:" }, { "from": "agent", "value": "Graft related sepsis" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 68-year old male, with a past medical history remarkable for an 88 pack-year smoking history and chronic obstructive pulmonary disease on supplemental oxygen, underwent an annual lung cancer screening with a computed tomography (CT) scan of the chest ordered by his primary care physician. CT demonstrated an increase in previously identified lung nodules as well as five new nodules, fluid within the right lung and ipsilateral mediastinal adenopathy. Subsequent bronchoscopy and lymph node biopsies demonstrated pulmonary adenocarcinoma that was EGFR negative, ALK negative, ROS1 negative, BRAF wild type, and highly positive for programmed cell death protein 1 (PD-1) (>50%) with a tumor proportion score of 100%. Surveillance magnetic resonance imaging (MRI) of the brain (1 mm cuts) demonstrated a single, avidly enhancing 11 x 7 x 12 mm lesion along the mesial surface of the right frontal lobe within the cingulate sulcus with surrounding vasogenic edema (Figures 1A,B). As such, his primary disease was considered stage IV (T0N2M1b). He was started on pembrolizumab immunotherapy by medical oncology and referred to neurosurgery for further treatment considerations of his single metastatic intracranial lesion. Risks and benefits of treating and withholding treatment for the single metastatic intracranial lesion were discussed at length with the patient. Given the patient's poor pulmonary status and the location of the brain metastasis, we recommended SRS. However, the patient refused treatment other than pembrolizumab but was amenable to considering intervention should the lesion progress on follow-up imaging. Four cycles of pembrolizumab (200 mg every 3 weeks) were planned with follow up MRI thereafter to revisit treatment options based upon imaging findings. Repeat MRI (1 mm cuts) 3 months after initiating pembrolizumab demonstrated complete radiographic resolution of the intracranial lesion and associated vasogenic edema without any new interim findings (Figures 1C,D). Follow-up positron-emission tomography 9 months after starting treatment demonstrated no focal accumulations within the brain parenchyma but with persistent yet decreased uptake within the right upper lobe, two areas of new uptake and interval resolution of mediastinal and hilar lymph node activity. The patient completed ten cycles of pembrolizumab without any reported clinical sequelae throughout his treatment course. At 1-year follow up after initial diagnosis, the patient was doing well with his pulmonary function at baseline.\nOUTPUT:" }, { "from": "agent", "value": "Non-small Cell Lung Cancer With Brain Metastasis" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: The post-operative course was complicated by significant abdominal pain, nausea, and vomiting refractory to conservative management. Endoscopic retrograde cholangiopancreatography (ERCP) with biliary sphincterotomy was pursued and a 10 French by 7 cm trans-papillary biliary stent was placed. Cholangiogram demonstrated a non-dilated normal appearing biliary system without contrast extravasation. Due to persistent symptoms, a right upper ultrasound was performed revealing a small 1.7 cm fluid collection in the gallbladder fossa, which was not amenable to percutaneous drainage. She was discharged after optimization of pain management but represented six days later with symptom relapse. Her percutaneous drain was removed four days later when CT demonstrated a reduction in size of collection. She continued to have persistent right upper quadrant (RUQ) pain. The patient chose to transfer care to another hospital and underwent segmental hepatic resection and fistula closure with symptom resolution.\nOUTPUT:" }, { "from": "agent", "value": "Chronic cholecystitis, Bile leak, Biloma, Bile duct injury, Variant biliary anatomy, Fistulous connection between hepatic segments 6 and 7 and the duodenal cap" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: The patient was a 75-year-old female with an 8-month history of worsening dysphagia, to both solids and liquids and epigastric pain, burning in nature, radiating to the chest, costal margin, and back. Just before presentation, she experienced nausea and frequent (10-30 minutes) episodes of projectile vomiting, not related to oral intake. The patient had suffered from diarrhoea for a week prior to presentation, with no reports of blood or mucous in her stool. Generalised weakness, lethargy, reduced appetite, and a weight loss of 16 Kgs in 6 months were also reported. Past medical history was significant for hypertension and chronic obstructive pulmonary disease (COPD) under medical control. During the clinical examination, the patient was found to have a distended, but soft abdomen. Generalised tenderness, mainly to the right side and particularly during deep palpation, was noted. No organomegaly or masses were detected. Bowel sounds were present and active. Rectal examination was unremarkable. The rest of the clinical examination only revealed bilateral pitting oedema of the ankles and swollen hands with \"sausage-like\" digits. The patient was initially investigated with an oesophagogastroduodenoscopy (OGD), which diagnosed Candida oesophagitis (possibly due to the inhaled steroids for the COPD) and mild chronic non-active inflammation of the gastric mucosa on biopsy. However, it also identified an extrinsic compression of the gastric antrum and therefore a computer tomography (CT) of the abdomen and pelvis was performed. The CT showed moderately dilated small bowel loops with gas within the intestinal wall (Figure 1). Since the patient's clinical condition was stable and did not demonstrate signs of peritonism, a decision for conservative management was made. After excluding life-threatening and acute causes of PI, such as infection or ischemia, further investigations were performed guided towards the more uncommon pathologies. Similarly, no signs related to the disease, such as skin thickening, calcinosis, or telangiectasia, were identified. The patient improved on methotrexate and was discharged after a total of 4 weeks hospital stay with appropriate outpatient follow-up.\nOUTPUT:" }, { "from": "agent", "value": "Systemic sclerosis" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 68-year-old man was taking talutireline hydrate for MSA that was diagnosed at the age of 65 years. He suffered from femoral neck fracture and performed humeral head placement at the age of 67 years. His lumbar and total hip BMD values were 0.728 and 0.685 g/cm2, respectively. We commenced denosumab without vitamin D or calcium at 1 year after surgery as he refused to take it due to the difficulty in swallowing vitamin D or calcium. No complications including hypocalcemia occurred during the treatment course (Table 1). His lumbar and hip BMD values improved to 0.803 (10.3% increase) and 0.707 (3.2% increase), respectively, at 18 months afterward (Table 2 and Figure 1). No fractures occurred during denosumab treatment. As his disease condition of MSA became worse around 6-8 months after the start of denosumab therapy, he started using a T-shaped case, whereas he could walk without any items before then. BMD was measured using a dual-energy X-ray absorption fan-beam bone densitometer (Lunar Prodigy; GE Healthcare Bio-Sciences Corp., Piscataway, NJ, USA) at the L1-4 levels of the posteroanterior spine and bilateral total hips. BAP was measured as a bone formation marker by a chemiluminescent enzyme immunoassay, urinary NTX and TRACP-5b were measured by an enzyme-linked immunosorbent assay, and 1,25(OH)2D3 was measured by an immunoradiometric assay. This study was approved by the institutional ethical review board at Shinshu University School of Medicine (#2365) prior to its start and was in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki for research involving human subjects. Written informed consent was provided by the two patients to have the case details and any accompanying data published.\nOUTPUT:" }, { "from": "agent", "value": "Multiple-system atrophy, Osteoporosis" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: He sought medical attention at our hospital two weeks after the injury. However, the rehabilitation did not begin until four months after the injury. MMT at the beginning of the rehabilitation on the affected side was as follows: deltoid, 2; biceps brachii, 2; triceps brachii, 4; wrist flexion muscles, 4; wrist extension muscles, 4; lumbricals, 4; and interosseous muscle, 4. His sensory function was only impaired in the region innervated by the axillary nerve. The assessment of ADL performance revealed that he was fully independent with the use of the unaffected limb. The preoperative rehabilitation involved ROM exercises and strengthening of the remaining muscles. Since surgical reconstruction of elbow flexion was planned, the focus was on strengthening of the muscle groups involved in wrist flexion and extension (Figure 5). Recovery of the biceps brachii muscle (elbow flexion strength) stopped at MMT grade 2; thus, the modified SLM procedure was performed one year and five months after the injury. After immobilization with a cast for five weeks, the patient began training of the range of elbow flexion with active motions of the transferred muscle with the support of a sling. Simultaneously, the patient underwent active training of the wrist extensor muscles. Subsequently, he underwent active elbow flexion training, and we initiated manual resistance active elbow flexion training at four months postoperatively. At six months postoperatively, the patient achieved excellent elbow flexion strength (MMT 4), and the active range of elbow flexion increased from 0 preoperatively to 120 postoperatively (Figure 6). The patient was able to lift a plastic bottle up to his mouth. At 12 months postoperatively, his elbow flexion strength remained at MMT 4 and the active range of elbow flexion increased to 145 . The preoperative MMT of the wrist extensor muscle group was 4, and it increased to 5 at 12 months postoperatively. Active ranges of elbow extension, forearm pronation/supination, and wrist flexion/extension at 12 months after surgery were -20 , full range, and full range, respectively. As with the patient in Case 1, the patient in this case was also able to carry a 5 kg object with both hands.\nOUTPUT:" }, { "from": "agent", "value": "Traumatic Brachial Plexus Injuries" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: The patient is a 58 years old Iraqi male that referred to our center three months after an unsuccessful operation for removing a subhepatic mass, probably adrenal mass. He experienced general weakness, fatigue, and weight loss in the last several months. The patient BMI was 20 kg/m2. In physical examination, vital signs were normal. In abdominal examination, a scar of previous surgery in the right subcostal area (subcostal incision) with near 15 cm length was noted. In hematological examination, Hb was 11 g/dl. In serum biochemistry, renal function tests, electrolytes, and bilirubin were all within normal limits. Only mild elevations of hepatic enzymes were noted. Serum and urinary catecholamines were normal. Serum levels of cortisole and aldosterone were normal. In CT scan that was done with intravenous and oral contrast (Figure 1), a large mass located in the subhepatic area and intervening with the upper pole of the right kidney was noted. In the report of previous operation that was done in Iraq, tumorectomy was failed due to severe adhesions of the mass to the peripheral tissues. This mass was isolated from the liver. The patient scheduled for right adrenalectomy with the midline laparotomy incision. After opening the layers, the mass was located in the lodge of upper pole of the right kidney. It was severely adherent to the peripheral tissues, due to severe adhesion of the mass to the subhepatic area, its differentiation from the kidney or adrenal was difficult. Due to severe bleeding from the subhepatic bed subcapsular resection of the mass with the adherent kidney performed. Its total size was 14 cm x 10 cm and it weighted 2250 grams. The postoperative course was uneventful and the patient discharged home at fourth postoperative day uneventfully. The patient was well one year after operation without any chemo or radiotherapy.\nOUTPUT:" }, { "from": "agent", "value": "Renal cell carcinoma, clear cell type, Fuhrman nuclear grading 2" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: KA is a 50-year-old premenopausal parous female who presented for imaging at the age of 45 years with a history of a right breast lump of 6 months' duration. Right sonomammography performed at the Radiology Department, UCH, with a Logiq P5 GE ultrasound machine using the high frequency linear transducer (10 MHz) at her first presentation showed a poorly circumscribed mixed echogenic mass at the 12 o'clock position measuring 4.9 x 3.2 cm. The mass showed specks of calcifications within it. The Doppler interrogation showed evidence of increased vascularity. A final BI-RADS category of 4 (suspicious for malignancy) was assigned to the study (Figure 2). Conventional mammography performed in the same department confirmed a poorly defined mass with microcalcifications and architectural distortion at the 12 o'clock position. The left breast at the time of the study was normal on both imaging modalities. She subsequently had an ultrasound-guided CNB of the right breast lump and the histopathological report confirmed IDC (Figure 3). The immunochemistry report was triple-negative. She immediately commenced neoadjuvant chemotherapy and later had modified right radical mastectomy. After surgery, she had adjuvant chemo- and radiotherapy. She was a compliant patient who had remission for approximately 5 years; during this period, she was off chemotherapeutic drugs. She developed a painless progressive lump in the contralateral breast 5 years later and presented to the surgical outpatient clinic. On examination, there was a palpable left breast mass with associated bloody nipple discharge, which was confirmed on sonomammography. Histological examination of the ultrasound-guided CNB specimen of the contralateral mass confirmed it to be an IDC. She then had modified left radical mastectomy after adjuvant chemotherapy and has since been placed on paclitaxel and radiotherapy.\nOUTPUT:" }, { "from": "agent", "value": "Bilateral breast cancer" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: Faced with the persistence of symptoms, she consulted the emergency room. The patient stated that she had breathing discomfort occurring within 8 hours. Physical examination revealed: right and left non-invasive brachial blood pressures were 100/60mmHg and 115/50mmHg, respectively. Cardiac auscultation detected a murmur of a diastolic regurgitation at the right second intercostal space. The size of the abdomen was consistent with gestational age, foetal heart rate tracing was reassuring. Based on these findings, the patient was referred to the Cardiovascular surgery department for Bentall surgery and urgent cesarean delivery in coordination with the gynecologists.\nOUTPUT:" }, { "from": "agent", "value": "Aortic dissection" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: Patient 2 was a 36-year-old G6P3 with a history of hypothyroidism, asthma, and obesity who was diagnosed with PPCM after presenting with dyspnea on exertion, weight gain, and orthopnea 6 weeks after the birth of her third child. She had had 2 uncomplicated pregnancies followed by 3 first-trimester spontaneous abortions. All 3 pregnancies that were carried to delivery were complicated by preeclampsia. Symptoms developed 2 weeks after delivery, and she was treated for asthma exacerbation and evaluated for pulmonary embolism prior to establishing a diagnosis. Echocardiogram at admission revealed an EF of 10%. She underwent diuresis and was discharged on captopril, carvedilol, furosemide, and digoxin. Over the next 11 years, she consistently remained on an angiotensin-converting enzyme inhibitor and a beta-blocker with no documented concerns regarding medication adherence. Serial echocardiograms were undertaken for monitoring purposes. Time to EF normalization was 3.0 years after diagnosis when her EF was measured at 55%. She remained without symptoms of heart failure for the first 8 years after diagnosis when she developed dyspnea on exertion and lower extremity edema. However, her clinical picture was complicated by progressive obesity and deconditioning. Ejection fraction (EF) at that time declined to a nadir of 42.5% without apparent trigger; there was no mention of medication noncompliance, viral illness, or concern for ischemia. At the time, she was taking lisinopril 20 mg twice daily and metoprolol succinate 100 mg daily. She subsequently moved out of the area and changed cardiologists. A time line of the patients' LVEF and other LV dimensions are shown in Tables 1 and 2.\nOUTPUT:" }, { "from": "agent", "value": "Peripartum Cardiomyopathy" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: Workup included a CT-scan, which revealed severe terminal ileitis adherent to the right lobe of the liver along with a 3.9 cm x 3.5 cm hepatic abscess in the right lobe (Fig. 1, Fig. 2). She underwent conservative management with antibiotics and Vascular Interventional Radiology drained the abscess percutaneously, as was standard of care. She was counseled about her surgical options, which included both the laparoscopic and open approaches after failing conservative management, which necessitated surgery. She underwent an extensive laparoscopic lysis of adhesions, marsupialization of the liver abscess, and ileocecal resection a month later by an experienced laparoscopic colorectal surgeon. The inflamed, segment of terminal ileum was densely adhered to the liver. There were essentially no tissue planes and the terminal ileum was significantly adhesed to the liver, as were the cecum and appendix. These were meticulously dissected off the visceral surface of the liver. We enlarged the fistulous opening and encountered a 5 cm x 6 cm abscess cavity filled with pus and enteric contents. This was adequately drained and the cavity was marsupialized. Approximately 23 cm of small bowel was removed, as well. The patient recovered well from the surgery and was gradually weaned off her prednisone. She was followed in the clinic postoperatively in normal routine fashion and did well. She reported no further abscesses or problems with her liver in the interim five years. Her postoperative recovery was also uneventful. This case report was approved by our Institutional Review Board, has been reported in compliance with the SCARE criteria and we have obtained the patient's permission to publish this case report.\nOUTPUT:" }, { "from": "agent", "value": "Enterohepatic fistula, Crohn's Disease" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: He had been found by the court to be not guilty by reason of mental impairment, being unwell at the time of his latest offence, experiencing bizarre persecutory delusions and command hallucinations of a homicidal and suicidal nature. He had a long history of violent offences and noncompliance with medication. His illness was exacerbated by drug abuse, particularly amphetamines. It was slowly titrated to a total dose of 400 mg per day, at which his serum levels ranged between 510 and 975 micrograms per litre. He responded, but later complained of restless legs, which contributed to episodes of nonadherence to medication. Clozapine was reduced to 350 mg per day, but similar problems continued, and it was gradually withdrawn, leading to deterioration in his mental state. Paliperidone long-acting injection was initiated instead and maintained at 150 mg monthly. Although his mental state improved, it fluctuated greatly, making discharge unsafe. As an adjunct to his primary treatment with paliperidone, clozapine was reintroduced and titrated to 150 mg daily, later 200 mg after slight deterioration in mental state. At this dose, his serum levels ranged between 137 and 254 micrograms per litre, substantially below the levels usually regarded as therapeutic. There was a significant improvement in his mental state and insight. He did continue to experience mild persecutory ideas and auditory hallucinations, but they did not fluctuate as they had before. He went on to use amphetamines twice during his rehabilitation; however, they did not have the severe negative impact on his mental state as previously. His insight allowed him to admit to his use and continues to work with services on relapse prevention. He was subsequently discharged.\nOUTPUT:" }, { "from": "agent", "value": "Paranoid Schizophrenia" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 22-year-old male presented with acute retention of urine and an enlarged and tender prostate. There was no history of sexual contact and human immunodeficiency virus (HIV) serology was negative. Urine examination showed 20 pus cells/hpf. TRUS revealed ill-defined hypoechoic areas in the peripheral zone of the prostate. MRI was performed using T2W fast spin-echo, pre- and postgadolinium-enhanced T1W spin-echo and DWI sequences on a 3.0- Tesla MRI unit (Verio; Siemens, Erlangen, Germany). For DWI, we used a single-shot echo- planar imaging EPI sequence with TR/TE/3000/79 ms, b factors of 50/400/800 s/mm2, 10 averages, 4-mm slices with a parallel acquisition technique PAT factor of 2 (generalized autocalibrating partial parallel acquisition-GRAPPA) leading to a time of 4.41 min for acquisition of a three-directional trace and apparent diffusion coefficient (ADC) maps. It revealed multiple foci of a T2-hyperintense signal [Figure 1A] in the peripheral part of the prostate, poorly visualized on T1W images [Figure 1B] with peripheral enhancement on postgadolinium images [Figure 1C]. The DWI revealed diffusion restriction in the lesions [Figure 1D]. The corresponding ADC map revealed low signal [Figure 1E], with mean values of 0.63 +- 0.07 x 10-3 mm2/s, using an average of 5 ROIs of 0.08 sq cm each. The urine culture was sterile. The patient improved after administration of antibiotics (ofloxacin) for 4 weeks.\nOUTPUT:" }, { "from": "agent", "value": "Prostatic Abscess" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: In integrative single-case studies, we combine these qualitative and quantitative research aspects under conditions of \"life as it is lived.\" The study design requires that subjects collect their entire urine in 12-h intervals (biological), fill out questionnaires in the morning and evening (psychological) and participate in weekly interviews to identify the previous week's emotionally meaningful daily incidents (social). In one integrative single-case study on a healthy 25-year-old female subject who collected biopsychosocial data over the course of 63 days, i.e., 126 12-h intervals, the use of linear time series analysis (i.e., ARIMA modeling, cross-correlational analysis) led to new findings in stress research. One of these findings was that urinary neopterin concentrations [a cellular immune parameter ] showed cyclic or biphasic response patterns lasting up to 60 h after the occurrence of emotionally meaningful everyday incidents. This suggests that the emotional processing of incidents takes days and is accompanied by a psycho-immunological regulatory feedback mechanism. This finding is in line with the fact that in real-life, no physiological variables result in perfect constancy or periodicity, but rather are blurred by fluctuations around an underlying process. Such irregularities can be seen as noise, referring to unexplained variability from random influences, such as ever-changing environmental factors that force the organism to adapt, or as chaos resulting from a deterministic system with non-linear cause-effect relations. The cyclic psychobiological response patterns found in the original study may indeed be indications of such dynamics. Consequently, for a further understanding of the subject's biopsychosocial dynamics during the study period, an expansion of the applied statistical method is necessary from linear to non-linear. Thus, the current re-evaluation of the original data set used a dynamic complexity measure to further analyze the connection between the psychosocial incidents identified as meaningful to the subject and her cellular immune functioning, as indicated by neopterin. (2) Are such neopterin complexity patterns temporally and, moreover, functionally related to the occurrence of emotionally meaningful psychosocial incidents?\nOUTPUT:" }, { "from": "agent", "value": "No specific diagnosis" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 79-year-old female with multiple comorbidities and on percutaneous enteral gastrostomy (PEG) feeding for the preceding four years was admitted with suspected PEG tube site infection. After cultures from the site revealed methicillin-resistant Staphylococcus aureus (MRSA), the PEG tube was removed and a small-bore NGT-Dobhoff tube was inserted by a resident physician for feeding. After initial resistance was observed by the performing physician, the procedure was continued until the tip of the tube was 50 cm from the incisors. Correct placement was checked by auscultation over the epigastrium and a chest X-ray was performed to confirm the correct position of the tube. A few minutes post-insertion, while awaiting X-ray to confirm tube position, the patient developed shortness of breath and desaturation. 1A). The patient's family was notified of the inadvertent event and the NG tube was immediately removed and a right chest tube inserted. 1B). 2A). 2B).\nOUTPUT:" }, { "from": "agent", "value": "Lung laceration, Right-sided pneumothorax, Diaphragmatic injury, Hospital-acquired pneumonia" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: An 11-year-old boy presented to us after falling accidentally on a metal rod six hours after the incident. He was walking home from school, slid and fell on a metal rod with a curved end in an abandoned construction site. He was brought to the hospital in a private car by his mother directly after the incident. The iron rod went through his anal orifice. The child reported of some lower abdominal pain that was accompanied by some fresh bleeding from the rectum. The child denied urine incontinence. Upon examination he was a well nourished child, fully alert, in moderate pain, mild conjunctival pallor, saturating at 95% on room air, pulse rate of 104 beats per minute, blood pressure of 98/65 mmHg and had axillary temperature of 38 C. On local examination, there were no perianal injuries noted with normal anal verge and muscle tone but a rod into the anal orifice (Figure 1). His abdomen moved with respiration, had rebound tenderness and guarding, with reduced bowel sounds. Plain abdominal pelvic x-rays were done showing the rod in the rectum with no surrounding emphysema (Figure 2). The boy was given tetanus toxoid, intravenous Ceftriaxone, Metronidazole and Paracetamol as pre and post operative antibiotics. Intra-operatively, through a midline incision, there was turbid ascites that was not foul smelling. The iron rod hook noted in the abdominal cavity having perforated the anterior part of the rectum at the peritoneal reflection (Figure 3). The rod was extracted abdominally, refreshening and primary closure done of the rectum. The iron rod was hooked at one end, approximately a meter long, weighed about 400 grams and did not have rust on its surface (Figure 4). The boy fared well post operatively and was nursed in the general ward for four days before being discharged, as his vitals were within range with no complications encountered during the operation. During his stay there was no signs and symptoms of local and systemic infection and was passing stools normally per rectally. He was then reviewed at the outpatient unit three weeks later whereby his abdominal incision had healed, did not have any abdominal signs or symptoms and had resumed his normal activities including schooling.\nOUTPUT:" }, { "from": "agent", "value": "Peritonitis due to perforated bowel" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: I read with interest the case report by Ahmad et al. The authors interestingly described the clinical presentation, imaging and histopathologic findings, and treatment protocol in the studied patient. I presume that the highly aggressive nature of the tumor and its rare occurrence at an unusual site should alert the authors to consider jeopardized immune status in the studied patient. My presumption is based on the following point. More than half of the health-care facilities are closed or partly functioning with the exodus of more than half of the health professionals.\nOUTPUT:" }, { "from": "agent", "value": "Orbital rhabdomyosarcoma, HIV infection" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 55-year-old white male lawyer presented to the emergency department with a fever, persistent cough and shortness of breath beginning five days earlier. Past medical history revealed no previous serious illnesses. The patient never smoked. Chest X-ray showed a right upper lobe infiltrate. Blood testing revealed leukocytosis and a high C-reactive protein. A diagnosis of right sided pneumonia was made and the patient was admitted to the hospital's Internal Medicine Department. Antibiotic therapy was started but fever and symptoms failed to respond. Due to the persistence of the symptoms and the presence of graysh/black sputum, chest computed tomography was performed. This revealed mixed ground-glass and lobar consolidation involving the right superior lobe, with associated air bronchograms and thickened interlobular septa, patchy areas of ground-glass in the middle and inferior lobe with air bronchograms and thickened interlobular septa and multiple bilateral nodules of varying size. Tumor markers were within the normal range. Bronchoscopic examination showed a bulging lesion in the bronchus of the lower left lobe, and BAL revealed presence of melanocytes. Careful skin examination showed a small lesion at the left shoulder and another at the left limb. The patient underwent surgical removal of the two lesions. The histopatological report described aggregates of atypical melanocytes within the dermis with thinning of the epidermis, no lateral extension of atypical melanocytes within the epidermis, absence of inflammatory infiltrate and junctional activity. This was reported as a characteristic pattern of metastatic malignant melanoma (MM). A CT scan of the brain revealed multiple secondary lesions. Detailed neurologic evaluation revealed the absence of any clinical neurological deficit. Comprehensive ophthalmologic examination showed no evidence of ocular melanoma. A CT guided lung biopsy showed submucosal malignant epithelioid cells with large amounts of acidophilic cytoplasm and prominent nuclei. Dark brown pigment was observed in some of the tumor cells (Fig. 1). Mitotic figures were prominent. Immunohistochemical staining demonstrated positivity for pan-melanoma, S-100 protein, Vimentin, and HMB45 (melanoma marker), and were negative for cytokeratin (CK), epithelial membrane. The patient was referred to the local University Melanoma Center where he was treated with chemotherapy and immunotherapy. Despite therapy, the patient died three months after the diagnosis.\nOUTPUT:" }, { "from": "agent", "value": "Primary lung malignant melanoma with multiple pulmonary, cerebral and skin metastases" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 36-year-old male patient presented for evaluation of a 3-month history of behavioral changes and poor sleep. There was no history of fever or seizures. The patient presented with episodes of odd behavior, restlessness, irritability, aggressiveness, and agitation. There were sporadic visual hallucinations. Neurological examination was remarkable for fluctuating mental confusion with disorientation and bilateral upper limb resting tremor. There was no focal paralysis. Nuchal rigidity and Kernig's and Brudzinski's signs were all negative. Brain MRI showed diffuse leptomeningeal enhancement with scattered non-enhancing hyperintensities in the white matter ( Figures 1A, B ). EEG showed diffuse slow waves in the bilateral frontal lobes and bilateral centrotemporal regions, mostly on the right side. Lumbar puncture revealed an opening pressure of 150 mmH2O, and the CSF showed elevated WBC, 39 x 106/L (normal <=5 x 106/L); lymphocytes, 74%; proteins, 0.28 g/L (normal: 0.15-0.45 g/L); and glucose, 3.4 mmol/L (range: 2.5-4 mmol/L). The patient had positive GAD65 Abs in the serum 1:10, but these Abs were negative in the CSF. Investigations for infectious causes were all negative. Treatment with progressively higher doses of risperidone did not provide benefit. However, marked clinical improvement was observed following treatment with oral methylprednisolone 40 mg per day for 2 weeks followed by progressively decreasing doses of 4 mg every week. The patient achieved an mRS score of 0 at the 16-month follow-up, after the onset of symptoms.\nOUTPUT:" }, { "from": "agent", "value": "Meningoencephalitis associated with GAD65 autoimmunity, Type 2 diabetes mellitus" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 46-year-old male, with no known medical illness, presented to the emergency room (ER) with 3 days' history of worsening severe generalized headache more over the frontal head region and neck pain. These symptoms were associated with right-sided weakness and focal seizures with secondary generalization. His general physical examination was unremarkable, while neurological examination showed normal higher mental function, bilateral mild papilledema, and mild right-sided weakness with extensor planter response. A non-contrast brain CT scan in the ER showed SAH in paramedian sulci bilaterally more over the left fronto-parietal region (Figure 1A). Neurosurgery attended the case in the ER and admitted him as a case of SAH for work up. The CT angiography was negative for aneurysmal bleed, and follow up CT brain showed venous infarct. The neurology service then took over the case and proceeded for MRI with venography (MRV), which showed obscuration of antero-superior portion of SSS and draining veins especially on right side (in lateral view, Figure 1B) as well as transverse and sigmoid sinuses in (maximum intensity projection [MIP] anterior oblique view, Figure 1C). Fluid-attenuated inversion recovery (FLAIR) images showed the areas of hyperintensity bilaterally in frontal and parietal regions consistent with venous infarcts (Figure 1D). He was treated with body weight adjusted subcutaneous anticoagulation. Patient's headache subsided within a week, and his neurological signs improved over 4 weeks. Etiological work up including thrombophilia testing was negative. He continued to take oral anticoagulation as an outpatient, which was continued for 6 months, and the International Normalization ratio (INR) was maintained between 2-3. At present he is seizure free, and is maintained on antiepileptic drugs.\nOUTPUT:" }, { "from": "agent", "value": "Acute subarachnoid hemorrhage, Cerebral venous sinus thrombosis" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 60 kg, 23-year-old man was scheduled for DL assessment and further surgery. The t-tube was needed, as 70 endoscopy had revealed the presence of a web between true and false vocal cords, which had reduced the glottis chink. All the relevant investigations were within normal limits. The patient's upper airway was anesthetized by 10% lignocaine viscus gargles and nebulization of 6 ml 4% lignocaine, using a tight fitting mask and standard nebulizer. Glycopyrrolate 0.2 mg was administered intramuscular as an antisialagogue. After shifting the patient to OT, intravenous (IV) access was secured and standard monitors were applied. A No. 4 endotracheal tube (ET) connector was found to fit into the extraluminal limb of t-piece. Patient was preoxygenated with 100% oxygen through the Bain's circuit connected to the extraluminal limb of t-tube with the ET connector and capnometer sampler attached. Patient was administered IV ranitidine 50 mg, metoclopramide 10 mg, midazolam 1 mg and fentanyl 100 mcg slowly. Anesthesia was induced by inhalation of 3-4% sevoflurane in 100% oxygen on spontaneous breathing and was maintained with 2-3% sevoflurane in oxygen and nitrous oxide mixture (50:50). After ensuring adequate ventilation and depth of anesthesia, DL assessment was started without any significant change in hemodynamic parameters. During the procedure, surgeons blocked the upper open intraluminal end of the t-tube with a piece of ribbon gauze, sufficient to prevent air leak without compromising surgical view. The rest of the procedure was performed satisfactorily on assisted spontaneous breathing with minimal leakage of gas through upper open end. At the end of procedure the ribbon gauze was removed from the upper end of t-tube. The anesthetic gases were discontinued and 100% oxygen was administered. The patient became conscious, was breathing adequately through the t-tube and maintaining oxygen saturation of 99% on room air. Patient was shifted to the recovery room with stable vital parameters.\nOUTPUT:" }, { "from": "agent", "value": "Subglottic stenosis" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 62-year-old woman was treated via flank incision for a left pielolithotomy two years ago. Painless bulging at the surgical site appeared six months after the surgery. A laparoscopic surgical approach was chosen for treatment of the patient. Antibiotic prophylaxis was performed with cephalothin. The patient was placed in the right flank position, with the table tilted at 60 . A 4-cm umbilical incision was created to insert a single-port device (Gelport, Applied Medical Research, Rancho Santa Margarita, CA). Pneumoperitoneum with CO2 was maintained at a pressure of 15 mmHg and a 0 camera was introduced. A 5-mm port and a 12-mm port were inserted at the Gelport, establishing triangulation among the instruments (Figure 1). Conventional laparoscopic instruments were used for the procedure. During this procedure, CO2 pressure was reduced to 7-10 mmHg to help to fix the mesh. Finally, the cavity was revised, the single-ports removed and the incision was closed. The total operative time was 100 minutes. No intraoperative event was observed, and bleeding was minimal. Analgesia was provided with only minor analgesics on the first postoperative day. The patient was discharged the day after the surgery. She is asymptomatic at the six-month follow-up and happy with the esthetic aspect (Figure 4).\nOUTPUT:" }, { "from": "agent", "value": "Lumbar hernia" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: The child was operated on the second day of life by the right laterodorsal thoracotomy. The tracheoesophageal fistula was dissected and sutured, and esophago-esophageal anastomosis was performed. Before closure, the lungs were aerated by forced ventilation, continued until all collapsed regions fully expanded. During postoperative course, on control chest X-rays, there was atelectasis in the upper lobe and the middle lobe of the right lung (Fig. 1). On ultrasound examination, no pleural effusion was noted. On the sixth postoperative day, contrast-enhanced computed tomographic (CT) scan was performed and revealed abrupt termination of the bronchial airways with atypical course of horizontal interlobal fissure (Fig. 2). and continued as a single bronchus to the lower lobe. There were neither any branches to the upper lobe nor to the middle lobe. Thus, bronchography was performed, which showed obstruction of the upper lobe bronchus and bronchus intermedius and the middle lobe bronchus of the right lung (Fig. 3).\nOUTPUT:" }, { "from": "agent", "value": "Pulmonary torsion, Congenital esophageal atresia" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 36 year old man from Somalia was transferred to our out-patient clinic from his GP. His medications consisted of insulin glargin 10 U q.d. and insulin lispro 4 U t.i.d. (thus a daily insulin dose of 22 U [0.29 U/kg b.w. ]), olanzapine 15 mg q.d., and slow release valproic acid 500 mg 2 b.i.d. Upon his first visit at our out-patient clinic, physical examination showed a BMI of 22.7 kg/m2 and was otherwise unremarkable. He had a B-HbA1c of 77 mmol/mol (9.5%) and fS-LDL-cholesterol concentration 2.9 mmol/l. He was negative for autoantibodies against GAD-65 and IA-2 and his C-peptide concentration rose from 0.915 to 1.07 nmol/l upon meal stimulation, indicating lack of autoimmunity and a robust insulin production. All insulin therapy was stopped and replaced with Qtern (saxagliptin 5 mg and dapagliflozin 10 mg) q.d., atorvastatin (40 mg q.d.) and varenicline as anti-smoking therapy. Upon revisiting the diabetes nurse 4 months later, his B-HbA1c was 40 mmol/mol (5.9%) and fS-LDL-cholesterol was 1.6 mmol/l, but he had not succeeded stopping smoking. The patient was referred back to his GP.\nOUTPUT:" }, { "from": "agent", "value": "Ketosis-Prone Type 2 Diabetes, Bipolar Disorder" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 2120 g female was delivered by cesarean section of 34 weeks because of a bigeminal gestation with an Apgar score of 8 in 1st minute and 9 in 5 minutes. The neonate passed meconium stools by the first hour after birth. Initially it was given parenteral feeding. Per os feeding was administrated on day 4 after birth. The neonate presented bilious vomiting and progressive abdominal distention on day 7. The feeding was progressively reduced and suppressed on day 9 due to bilious secretions from the nasogastric tube. Physical examination revealed a mild distended abdomen, hematological tests (WBC = 15300 /muL, Hgb = 12.4 g/dL, Hct = 39%, PLT = 302.000 /muL, CRP = 2.8, Glu = 97 mg/dL, Ure = 39 /mg/dL, Cre = 0.8 mg/dL, AST = 50 u/L, ALT = 42 u/L, Tbil = 1.63 mg/dL, Dbil = 0.53 mg/dL, K = 3.6 mmol/L, Na = 138 mmol/L, Cl = 102 mmol/L) ranged in normal with mild increasing of WBC and no bloody stools were presented. Antibiotics were given from the first day of life (3rd generation cephalosporines). On day 8 we performed an abdominal radiograph that demonstrated multiple air-filled bowel loops with mild dilatation of a few loops (Figure 1). Upper gastrointestinal study after the administration of gastrografin (on day 9) indicated a mild dilatation of the contrast filled loops and the presence of a significant amount of air, distal to the contrast filled loops that suggest an incomplete obstruction (Figure 2). The enema with gastrografin relieved a normal colon and ileocecal junction. On day 10 the child was operated on. The reduction was facile. No lead point was detected. The examination of the gastrointestinal tube proximal and distal is proved to be negative for other anomalies. The postoperative course was uneventful. The enteral feeding started at the 5th postoperative day and the child was discharged in an excellent general condition.\nOUTPUT:" }, { "from": "agent", "value": "Intussusception" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 41-year-old woman with a history of recurrent urinary tract infections over the past year presented to a city hospital with one week of dysuria and three days of right flank pain radiating to the groin, associated fever, nausea, myalgias, urinary urgency, frequency, hematuria, and malodorous urine. Reproductive history was significant for seven pregnancies which resulted in five full-term births and two abortions. Her only other medical and surgical history was that of intrauterine device placement and documented removal. In the emergency department, she was febrile to 101.1 F and hemodynamically stable. She had lower abdominal tenderness and right costovertebral angle tenderness. Urinalysis showed moderate leukocyte esterase, 30-50 WBCs, and moderate bacteria. Urine and blood cultures grew Enterococcus faecalis. With the patient positioned in low lithotomy to allow for transurethral access, abdominopelvic access was also obtained using the da Vinci robot. The large stone was seen attached to the strings of the IUD intravesically. Gentle pull of the intravesical strings was attempted, but no movement of the device was noted. With guidance of the cystoscope light for transillumination, the IUD was identified extravesically with robotic assistance (Figures 2(a) and 2(b)). Cystorraphy was performed with a figure-of-8 stitch. The patient recovered uneventfully and was discharged home the same day.\nOUTPUT:" }, { "from": "agent", "value": "IUD translocation into the bladder, Bladder calculus" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: Case 2 - A 6-year-4-month-old male patient presented with hand and body movements that increased in severity during the two years of schooling, leading to a marked decline in writing and fine motor skills during the infection periods. There were vocal tics in the form of oral throat cleaning. He also wanted his notebook and books placed in his bag in a certain order. School absenteeism increased due to increasing complaints during the periods of infection. Risperidone 0.25 mg/day had been started at the pediatric psychiatry clinic and he was referred to us because of no response. There was no psychiatric disease, especially OCD and tic disorder, in his family history. On physical examination, the patient had dancing like movements of the hands and legs and a vocal tick in the form of throat cleaning. There was a milking phenomenon in his hand and when he was asked to keep his tongue out of the mouth, he was able to achieve this for a short time. His body temperature was 37.8 oC. The oropharynx was markedly hyperemic and hypertrophic. In the laboratory tests, ASO was 927 IU-ml (0-200 IU-ml) and C-reactive protein was 38 mg/L (0-5 mg/L). White blood cell count increased (19.800). Anti-nuclear antibody, rheumatoid factor and biochemistry tests were normal. Echocardiography showed no cardiac involvement. Cranial magnetic resonance imaging and electroencephalography were normal. GAS-Streptococcus pyogenes grew in throat culture. Ampicillin-sulbactam was started intravenously. On the 3rd day of the treatment, his symptoms started to improve. Monthly Depot penicillin prophylaxis was started. Significant improvement was observed in the choreiform movements after six months.\nOUTPUT:" }, { "from": "agent", "value": "Streptococci Infections, Childhood Neuropsychiatric Disorders" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: On admission, thrombocytopenia (12,000/mm3) and anemia (8.0 g/dL) were observed (Table 1). Oral corticosteroid therapy was started with prednisone 1 mg/kg/day. On the third day of hospitalization, he had headache with vomiting, associated with mental confusion and, subsequently, motor aphasia and right hemiplegia. Considering the sudden worsening of the patient's overall conditions, he was referred to the intensive care unit. Nuclear magnetic resonance imaging of the brain was performed to rule out acute ischemic or hemorrhagic events. The neuroimaging examination showed no alterations. Faced with an acute neurological worsening, the possibility of TTP was considered. Analysis of the peripheral smear showed innumerable schizocytes, confirming the presence of TMA. Plasmapheresis and pulse therapy with methylprednisolone were started due to the hypothesis of TTP. Serological tests for hepatitis virus B and C were negative, as well as for retroviruses (only HIV). Regarding retroviruses, other representatives are not routinely investigated and, in this case, they were not suspected. The patient also had negative results for antinuclear antibody (ANA) (Table 2). There was a decrease in lactate dehydrogenase (LDH) (Table 1). Plasmapheresis was maintained until platelet counts remained higher than 150,000 for three consecutive days (Figure 1). Complete remission of neurological signs occurred after the first plasmapheresis.\nOUTPUT:" }, { "from": "agent", "value": "Thrombotic thrombocytopenic purpura, Dengue and Chikungunya virus coinfection" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: Case 1: a 54-year-old male patient was admitted with complaints of shortness of breath simultaneous abdominal pain, stiffness, and swelling. The patient was referred to specialist pulmonologist. Thorax CT scan revealed the presence of common pleural effusion on the right side of the patient and changes in the lung fields adjacent to the effusion revealed the presence of passive atelectasis. The presence of collapse and consolidation was revealed in the right lateral segment lung. Thoracic surgery consultation was requested for the patient because of the right pleural effusion. Thoracentesis was performed to the patient by the thoracic surgeon. Cytological examination of the material was reported to be compatible with malignant epithelial tumor. However, distinction of mesothelioma and carcinomatous adenocarcinoma could not be made as a result of cytopathology. He had no known previous exposure to asbestos. In abdominal examination, an abdominal mass was palpated in the right upper quadrant. Abdominal CT was also performed to the patient because of prolonged abdominal pain. In abdominal CT imaging, suspected invasion of omentum has been found in hepatic flexure and right transvers colon (Figure 1). In addition, suspected infiltration and signs of compression of these colonic segments were determined. Laparotomy was scheduled for the intraabdominal mass. Mass of the omentum adherent to the hepatic flexure was found in the operation. After dissection of adhesions, the patient underwent total omentectomy. There was no other pathology in the abdomen. After recovery, the patient was discharged. Patient was referred to medical oncology after the period of recovery. Chemotherapy was administered to the patient by the medical oncology specialist. Control abdominal CT was performed after six cycles of chemotherapy. Two cystic lesions were detected in CT. One of them was in size of 18 x 12 cm and located inferior of the right lobe of the liver and the other one was in size of 10 x 8 cm and located in right inferior quadrant. Percutaneous drainage was performed for both cysts. The patient was hospitalized until the cysts completely collapsed. The patient was discharged after recovery. Patient is in follow-up period.\nOUTPUT:" }, { "from": "agent", "value": "Malignant peritoneal mesothelioma" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: She has a familial history of inflammatory bowel disease, but no previous or concomitant diseases were reported. The patient's expanded disability status score (EDSS) at the time of referral was 6.5; concomitant medications were baclofen and levetiracetam. During the initial interview she described additional peculiar behaviors of her left hand frequently interfering with the activity of the other hand; for example, when she was opening a door or drawer with her right hand, she simultaneously pushed it shut with the left hand; on other occasions, she would open her pocket with the right hand but immediately her left hand would close it, or when choosing from the closet a pullover to dress, instead of taking the preferred one, sometimes she would find her left hand getting another, even from a different shelf. These behaviors did not always occur in the same situations and her left hand usually cooperated well with the right. She also reported occasional inability to move either the left or right hand at will during a task.\nOUTPUT:" }, { "from": "agent", "value": "Relapsing remitting MS, Secondary progressive MS, Focal epilepsy secondary to MS cortical lesions, Intermittent alien hand syndrome, Callosal apraxia" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A second patient was a 38-year-old G6P2 who underwent a secondary cesarean section which was performed for labor dystocia at GA 41 weeks. Her medical history revealed a secondary cesarean for fetal distress and a vaginal delivery. Both children were full-term and healthy. The pregnancy was complicated by recurrent vaginal blood loss in the second half, without any macroscopic cervical abnormalities seen at gynecologic examination. Cervical cytology at 27-week gestational age showed atypical squamous cells of undetermined significance, and the smear was scheduled to be repeated 6 weeks after delivery. The current delivery was induced for oligohydramnios. The cervix dilated to a maximum of 4 cm, despite good contractions. The cervix felt firm to hard in consistency. She delivered a healthy son, 4,084 g.\nAfter the diagnosis of SCC of the cervix, she was referred to our Gynecologic Oncology Department (RUNMC) and underwent an examination under anesthesia, revealing a severely altered cervix with a tumor measuring 5 cm involving the right parametrium. CT-scan showed no pathological lymph nodes, but due to the short postpartum interval the uterine cervix could not be assessed reliably. Since delivery by cesarean section might have led to spill of tumor cells intra-abdominally or might have provoked hematological metastasis, the patient received 6 courses neoadjuvant chemotherapy consisting of cisplatinum and placitaxel, both 70 mg/m2. Examination under anesthesia after chemotherapy showed a substantial decrease in tumor size to 1.5 cm.\nOUTPUT:" }, { "from": "agent", "value": "Pelvic malignancy, Grade 2 squamous cell carcinoma (SCC) of the cervix, Cervical cancer FIGO stage IIb" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 79 year old female presented with rapid onset of painless bilateral vision reduction. Previous ocular surgeries included laser iridotomy and phacoemulsification with posterior chamber intraocular lens (PCIOL) implants in both eyes several years prior. Her past medical history was significant for hypertension, congestive heart failure, atrial fibrillation, and coronary artery disease. Oral medications she was taking included dabigatran 150mg twice daily for atrial fibrillation which was initiated within the preceding 12 months. On presentation visual acuity was 20/400 in the right eye and 20/500 in the left eye. Intraocular pressure was within normal limits. Anterior segment exam revealed hyphema and fibrin accumulation (Figure 1A-B). Although fibrin was present, the predominant cell type present appeared to be red blood cells rather than white blood cells. Laboratory evaluation revealed no hematologic abnormalities. No significant abnormalities were identified. Given the spontaneous bleeding, dabigatran was immediately discontinued in consultation with the patient's cardiologist. Initial treatment included topical prednisolone and atropine. Following minimal response, the patient was also placed on a trial of oral prednisone 40 mg daily with minimal slow response (Figure 1C-D). The retina was unremarkable.\nOUTPUT:" }, { "from": "agent", "value": "Bilateral Spontaneous Hyphema, Vitreous Hemorrhage, and Choroidal Detachment" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 54-year-old man presented with an enlarging mass in right parotid gland for 2 months. Fifteen years earlier, he was found to have HIV infection. He was treated with highly active anti-retroviral therapy (HAART) efavirenz, abacavir and lamivudine, and had returned to a satisfactory state of health since then. At that time, the patient's CD4 count was 274 cells/ul, and the HIV ribonucleic acid (RNA) level was 50,928 copies/ml (Roche COBAS AmpliPrep/COBAS Taqman HIV-1 Test, v2.0). The high viral titer indicated suboptimal disease control as patient had poor drug compliance to HAART. Excisional biopsy of the right parotid mass revealed diffuse large B-cell lymphoma (DLBCL). The patient then underwent PET/CT for staging. Positron emission tomography/computed tomography demonstrated hypermetabolic right parotid mass and segment VIII liver mass [Figures 1 and 2]. The international prognostic index was 1 (for stage IV disease), which was identified as the low risk group. The patient was treated with combination chemotherapy with cyclophosphamide, doxorubicin, vincristine, and prednisolone (CHOP), and rituximab was integrated from the second cycle onwards. During the treatment period, the CD4 count of the patient remained at 155-359 cells/ul, while the HIV RNA level came down from 50,928 at the beginning of treatment to 54 copies/ml when treatment ended. Follow-up PET/CT after six cycles of chemo showed metabolic remission of right parotid and liver lesions. The patient was deemed to be in complete remission according to the International Workshop Criteria (IWC) (Cheson 2007). Treatment was therefore stopped at six cycles and the patient remained well at the latest follow-up.\nOUTPUT:" }, { "from": "agent", "value": "HIV Associated Non-Hodgkin's Lymphoma" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 49 year-old Caucasian woman came to the Emergency Department with colic abdominal pain, nausea and therapy-resistant vomiting for 4 days. She had an history of caesarean section performed many years earlier for benign gynecological pathology. She was afebrile and her physical examination revealed generalized abdominal distention and tenderness with tympanic bowel sounds. On laboratory investigation we saw WBC count of 14260/mm3, Hb 11.9 g/dL and C-reactive protein (CRP) 43.81 mg/L. Other routine laboratory tests were in the normal range. She had no other systemic symptoms and preoperative study showed no comorbidity. Family history was negative for relevant diseases. 1). Considering the previous gynecological surgery and the probable presence of a single adhesion band, despite the hyperdistension of the intestinal loops we preferred a laparoscopic approach with possible conversion to open surgery in presence of difficult exposure of working space. We induced pneumoperitoneum with Hasson tecnique using a 10-mm trans-umbilical optical trocar and after a careful exploration of the peritoneal cavity, we placed other two 5-mm trocars respectively in the right and left flank in order to scan pelvic and all abdominal quadrants. The ileal loop responsible of obstruction did not appear to be ischemic or necrotic. We performed an adequate laparoscopic adhesiolysis and detorsion of the involved ileal loop with no resection. Our patient had an uncomplicated postoperative course and was discharged on POD 5 in good health.\nOUTPUT:" }, { "from": "agent", "value": "Small bowel obstruction, Middle-ileal volvulus, Severe pelvic adhesion syndrome, Diffuse fibromatosis" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: Active physiotherapy was started from the 1st postoperative day under the cover of strong analgesics (intramuscular diclofenac sodium 3 mL BD). A Hester's jaw opener was used actively to open the mouth. The patient was discharged on the second postoperative day after a session of assisted physiotherapy. From the third postoperative day onwards, the patient was advised to report to our department every morning for a period of 2 months. Active physiotherapy using Hester's jaw opener was performed in the department. The patient was again attended to everyday in the evenings for a session of active physiotherapy and was also simultaneously encouraged. Targets were set for the patient to attain specific mouth openings till certain days to encourage him. In cases where a complaint of pain incapacitated the patient from doing physiotherapy, the attending surgeons personally helped the patient use the Hester's gradually. The patient was advised to perform physiotherapy himself using the jaw opener between these 2 assisted sessions of physiotherapy. Mouth opening was gradually increased and the wound was evaluated regularly. Wound was evaluated on the 10th postoperative day and certain loose sutures were removed. Betadine irrigation was also done. The characteristic hockey stick shaped uvula and the blanching of the palate associated with OSMF could also be observed clearly after surgery (Figure 5). 3rd postoperative day assisted mouth opening:21 mm (Figure 6)\n7th postoperative day assisted mouth opening:33 mm (Figure 7)\n1-month postoperative assisted mouth opening:40 mm (Figure 8)\n35-day postoperative passive mouth opening:35 mm (Figure 9)\n6-month postoperative passive mouth opening:43 mm (Figure 10)\nThe improvement in mouth opening observed was as follows:\nOUTPUT:" }, { "from": "agent", "value": "Oral Submucous Fibrosis" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: Only irrigation and drainage could be performed, because a primary closure was impossible due to the friability of the operated tissue. However, most of radiocontrast still leaked out 10 days after the second surgery. Endoscopy revealed near-total dehiscence of the anastomosis (Fig. 2A). Completely covered SEMS (Niti-S esophageal covered stent, 1.8x6.0 cm; Taewoong Medical Co., Goyang, Korea) was applied. However, the stent migrated distally 2 days after the insertion. Thus, we placed an anti-migration stent with 1.0-cm-wide uncovered proximal flanges and silk threads that linked its upper edge with the patient's earlobe (CHOOSTENT esophageal ST (CCN), 2.2x12.0 cm; M. I. Tech Co., Ltd.) after removing the migrated stent. Oral feeding was started after 2 weeks, and the drainage from the catheter stopped 4 weeks after the insertion of the stent. A follow-up radiocontrast study revealed no leakage, and the stent was removed 5 weeks after the second stent insertion. Minor bleeding occurred after the removal because the uncovered portion of the proximal flange was embedded in the mucosa. Follow-up endoscopy 10 days after the removal revealed complete healing of the dehiscence and bleeding site (Fig. 2B).\nOUTPUT:" }, { "from": "agent", "value": "Advanced gastric cancer, Pneumoperitoneum, Leakage from the esophagojejunal anastomosis" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: In a recent study, the same treatment protocol as utilized in the above research was used to evaluate the effects of the chronic microm-PEA treatment on reactive astrogliosis and neuronal function in the frontal cortex of 6-month-old 3xTg-AD mice, compared with their age-matched non-Tg littermates. Once again, microm-PEA demonstrated beneficial effects in reducing pathology-related biochemical alterations in this animal model of AD. In fact, 3-month microm-PEA treatment markedly reduced astrocytic activation in 3xTg-AD mice, as demonstrated by the decrease in GFAP mRNA and protein expression and the trend toward a decrease of S100B protein expression levels. Furthermore, chronic treatment reduced iNOS levels, slightly dampened the expression of Abeta, and increased the expression of BDNF in 3xTg-AD mice. Taken together, these findings indicate that early-symptomatic 3xTg-AD mice display signs of reactive gliosis in the frontal cortex and that the chronic microm-PEA may counteract such phenomenon, also improving the trophic support to neurons, in the absence of astrocytes and neuronal toxicity. To the best of our knowledge, current clinical studies of PEA are mostly related to pain or peripheral inflammatory-related conditions, while there are very few studies aimed at evaluating the possible beneficial effects of PEA on CNS-related pathologies in human beings. This could be due to the fact that very little is known about the pharmacokinetics of PEA in humans (please see Pharmacokinetic). In fact, the bioavailability and apparent volume of distribution have not been clearly evaluated; and blood PEA levels, at least in animals, do not accurately reflect levels in the CNS. The micronized or ultramicronized forms of PEA increased bioavailability in animals compared with naive forms, but there are very few and very recent clinical data to confirm that this is true for humans. Thus, while it seems likely that the new PEA formulations improve the compound bioavailability, complete pharmacokinetics data are urgently necessary to assess the precise tissue distribution and site of metabolism of PEA. These data will possibly allow to overcome the major difficulties in setting up clinical studies focused at evaluating the possible therapeutic role of PEA against CNS disorders.\nOUTPUT:" }, { "from": "agent", "value": "Alzheimer's Disease" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 16-year-old boy presented with 10 days history of decreased visual acuity and morning headaches. He had severe bilateral papilledema Grade IV, and visual acuity of counting fingers from the right eye and 20/400 from the left eye. MRI showed a complex solid cystic lesion in the right ventricle, that is, isointense in T2/FLAIR and T1 and intense contrast enhancement. An EVD was inserted to drain excessive CSF out of the ventricles, the tumor was reached through a transparietal approach to the right lateral ventricle. It was found to be firm and vascular. Near-total resection was achieved with a small highly vascular rim left on the temporal horn. Histopathological assessment of this tumor showed features of a CPP (WHO Grade I). The EVD was kept postoperatively to challenge CSF drainage and assess the need for a permanent shunt, and it was removed 5 days postoperatively. The patient kept having decreased visual acuity and persistent papilledema 2 weeks postoperatively and a VP shunt was inserted to relieve his persistent high intracranial pressure (ICP) symptoms. The patient needed a permanent VP shunt and continued to have decreased visual acuity with optic disc gliosis evidence on subsequent images. Five-year follow-up showed no tumor recurrence.\nOUTPUT:" }, { "from": "agent", "value": "Communicating hydrocephalus, Choroid plexus tumor" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A fully SARS-CoV2 vaccinated man in his 80 s, with a previous history of surgically treated bladder and prostate cancer, was referred to the emergency department because of fever, diarrhoea cough and progressive dyspnea. At admission, haemodynamics was stable and arterial blood gases (ABG) showed a moderate type-1 respiratory failure pattern (paO2 55 mmHg, SATO2 88%, paCO2 25 mmHg). Laboratory findings were consistent with severe inflammation in mild leukopenia (WBC 2.500/muL) and no serum electrolyte imbalance. A resting standard 12-lead electrocardiogram (EKG) showed sinus rhythm and normal repolarization. Nasopharyngeal swab testing for the SARS-CoV2 genome with the RT-PCR method was positive. Thus, the patient was addressed to our Internal Medicine Unit to continue adequate treatment and monitoring. Broad-spectrum antibiotics were also administered to cover possible associated bacterial infections. The diarrhoea stopped without further intervention. 1).\nOUTPUT:" }, { "from": "agent", "value": "Hyperkalemia, COVID-19 pneumonia, Unilateral pleural effusion" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: She was born at term and her mother had no remarkable past medical or obstetric history. The patient developed normally until the age of 4 months. At admission, the child presented with cough, fever, and dyspnea. The physical examination revealed tachypnea with subcostal and intercostal retractions. A plain chest x-ray showed a homogeneous opacity of the entire right hemithorax with cardiac displacement to the right and left lung hyperinflation. The patient was treated with intravenous fluids, oxygen, and antibiotics. Permission for autopsy was granted and an autopsy was performed. The thoracic cavity revealed a deviation and of the mediastinal structures to the right hemithorax, and hyperinflation of the left lung. The displaced heart showed normal anatomic relationship with the great arteries. No other cardiac or systemic malformations (Figure 2) were found.\nOUTPUT:" }, { "from": "agent", "value": "Pulmonary agenesis, Respiratory failure, Interstitial pneumonia" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: Patient information: an 11-year-old boy was admitted to the emergency department with persistent abdominal pain for 48hours with vomiting. The patient reported a history of intermittent pain with no specific symptoms for several months. No other relevant history was noted. Clinical findings: on admission, the patient had a fever (38.5 C). Abdominal examination showed a slight epigastric abdominal swelling, abdominal tenderness and pain in the right iliac fossa and epigastric region. Diagnostic assessment: blood tests revealed normal leukocytes count and high levels of inflammatory markers, but no other relevant findings. Abdominal ultrasound showed large peritoneal effusion related to peritonitis of probably appendicular origin. For further assessment, a computed tomography (CT) scan was advised but could not be done due to limited access to emergency care services. Therapeutic intervention: after resuscitation, an exploratory laparotomy was performed. We noticed multiple inflamed lymph nodes of different sizes (Figure 1). The patient underwent open resection of the cyst and appendectomy. Appropriate specimens were sent for the histopathological exams (Figure 2). After 5 days, the patient was discharged. Follow-up and outcome of interventions: the postoperative course was uneventful and there were no significant symptoms and no clinical evidence of recurrence during the 3-month follow-up. Fluid cytology was negative for malignancy. Informed consent: written informed consent was obtained from the patient and his parents for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.\nOUTPUT:" }, { "from": "agent", "value": "Acute appendicitis, Giant mesenteric pseudocyst" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: The 73 year old female patient was admitted to our orthopaedic department on the basis of intermittent pain in her left lower limb. At the time of her hospitalisation, she wasn`t able to walk anymore. The onset of symptoms was spontaneous; there was no history of trauma. No history of lumbago, no fever or weight loss. The symptoms were reported for the first time. The current medication comprised antihypertensive drugs, diuretics and an anticoagulans (cumarine). The patient reported a biologic aortal valve implantation from 6 months ago and an atrial fibrillation as a reason for the anticoagulation. On physical examination, we had an adipose female patient with a height of 165cm and weight of 95kg (BMI= 34.9). The mental status was normal. During the examination, the patient was asked to stand up for the purpose of inspection. While trying to get into a prone position, the patient lost control of her left lower limb. At this moment she also suffered urine incontinence the first time. On the left side, there was a loss of power for the hip flexion, knee extension and foot elevation, varying from 4/5 MRC (medical research council) grade to full plegia (Asia Impairment Scale AIS D to AIS C) and inability to move the limb during a second examination, which was performed 15 minutes later in the radiology department by the same examiner. Lasegue and Bragard sign was positive on the left side. Babinski sign was bilaterally negative. There was no saddle block anaesthesia present and the anal sphincter tonus was normal. Peripheral pulse status was also normal. Crural varicosis was inspected, but there was no change in limb circumference, color, temperature, pain on palpation of the calves nor near the great saphenous vein. There was no tenderness on the examination of the spine. Abdomen was smooth and also presented no tenderness to palpation. During the radiographic examination (changing position), the patient presented a rapid worsening of the paresis, not being able to move the affected limb. Because of undulating neurologic deficits in the lower limb, the patient was admitted to cranial computer tomography and magnetic resonance tomography examination of the spine.\nOUTPUT:" }, { "from": "agent", "value": "Sciatica, Incomplete paraplegia, Cumarine-induced coagulopathy" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: At the age of 13, the patient was fixed with plaster for a fracture of the femoral shaft, which resulted in a malunion. Because he was positive for inhibitors, the patient was re-examined regularly by the Haematology Clinic after discharge. The patient did not take any interventions during the first 4 months while being positive for inhibitors. During this period, the patient suffered from knee joint bleeding and recovered after ice compression and lying in bed. In the 5th month after the discovery of the inhibitors, the patient received irregular injections of factor VIII intravenously (1,000 IU, BIW or TIW, Kovaltry, Bayer), which did not follow the haematologist's recommendation. After 66 days of injections, he was still positive for inhibitors. Since then, the patient started to receive regular injections of factor VIII (1,500 IU, BID) intravenously. Forty-nine days after the first injection, he became negative for inhibitors (Table 1). The patient came to the hospital again 3 days prior to the surgery. His right foot could not touch the ground. The range of joint motion (ROM) was 20 -90 , the visual analogue scale (VAS) was 7 and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was 106 (Figure 1, Table 2). Other systemic examinations were normal.\nOUTPUT:" }, { "from": "agent", "value": "Haemophilia A, Haemophilic arthritis of right knee" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: Some of the patients require intensive care. As the reports show, the main treatment regimens include administration of benzodiazepines (midazolam) and of intravenous fluid (NaCl solution). Berar et al. The man with a history of drug consumption was admitted to the hospital with severe agitation and altered states of consciousness. Afterwards, the patient experienced nystagmus with dysarthria. His systolic/diastolic pressure was 158/131 mmHg, his HR was 100 beats/min, and his oxygen saturation was 99%. Laboratory tests showed hyperlactatemia (2.6 mmol/L), elevated creatine kinase levels (CK 290IU/L) and respiratory acidosis. Due to hypertonia, the patient was given 1 mg of midazolam and 1500 ml of saline solution. He was referred to the intensive care unit, where, in order to control anxiety and agitation, he received antipsychotic drugs: loxapine and cyamemazine. Additionally, the intravenous administration of electrolytes 3,000 ml/24h was continued. Within 24 h, neurological disorders, blood pressure and heart rate returned to baseline. The following day, the patient only experienced the effects of moderate sedation. He was referred to a psychiatric hospital, from which he was discharged after a few days. One week later he was hospitalized again after ingesting 50 mg of the same substance. On admission to the hospital, his vital signs were as follows: blood pressure 150/104 mmHg, HR 105 bpm, SpO2 96%. Mild psychomotor disorders and dysarthria were observed. The patient was discharged from the hospital after 12-h observation.\nOUTPUT:" }, { "from": "agent", "value": "PCP poisoning" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 1-year- and 2-month-old male toddler developed cough, grunting, fever, and few episodes of vomiting (blood streaked) for 2 days. Upon admission, he was tachypneic at 50 breaths per minute with a saturation of oxygen in room air of 88%. His temperature was 38.5 C and his pulse rate was 134 beats per minute. He was underweight at 6.7 kg. He had fine crepitations over his right lower one-third lung. After 5 days of intravenous ceftriaxone 75 mg/kg/day in two divided doses, oral azithromycin 10 mg/kg/day, subcutaneous enoxaparin 1 mg/kg/day in two divided doses, and intravenous dexamethasone 0.15 mg/kg/day as a single dose, his respiratory condition had not improved. His antibiotics were revised to intravenous vancomycin 60 mg/kg/day into four divided doses and cefepime 100 mg/kg/day into two divided doses which were given for 7 days. He required intermittent delivery of 0.5 L of oxygen per minute upon discharge following a 12-day hospitalization.\nOUTPUT:" }, { "from": "agent", "value": "Severe COVID-19, Patent ductus arteriosus, Pulmonary hypertension, Hospital-onset superimposed pneumonia" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 6-month-old girl was previously diagnosed with pure red cell aplasia. She developed fever, anuria, and progressive skin necrosis on the abdominal wall and buttock areas. Despite the antibiotic therapy (meropenem, amikacin, metronidazole) and the supportive therapy, her clinical conditions gradually worsened and, on day 10 after the PICU admission, the patient also needed respiratory support [non-invasive ventilation (NIV)] and showed a drastic increase of plasmatic urea/creatinine and all the inflammatory markers. Normal saline was used for the priming of the circuit and system testing; before connecting the device to the patient, normal saline was replaced with red blood cell suspension. After this first session of CVVHDF, all renal and inflammatory parameters rapidly improved, as summarized in Table 1. Importantly, the patient was also able to wean from the ventilatory support, and the FiO2 decreased from 60 to 30%; moreover, catecholamines were gradually discontinued. However, 5 days after the above treatment (day 15), the patient's clinical condition worsened again. Therefore, a second session of CVVHDF with HA-330 was performed, which resulted in similar improvements as reported in the previous episode (as shown in Table 1). No further CVVHF sessions were required, and the patient was discharged from the PICU 2 weeks later (day 29).\nOUTPUT:" }, { "from": "agent", "value": "Sepsis, Acute Kidney Injury" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 32-year-old male, resident of Nairobi came to India for treatment of his multiple medical complaints ranging from headache, abdominal pain, and constipation for the last 4 months. He had such headaches for the last 4 months with a frequency of 18-20 episodes/month. He had undergone multiple evaluations in his native country including hemogram, liver function, renal function, electrolytes, abdominal sonogram which were all normal and came to India contemplating doing magnetic resonance imaging of the brain and gastrointestinal endoscopy, for detailed evaluation. In view of all this symptoms, he was further inquired regarding any addiction to any drugs, which he denied. However, it was found that in Nigeria there is a social tradition in which on every weekend, the males of the community would gather and chew leaves of a plant called miraa/khat continuously for 12-16 h from Saturday afternoon until late night up to about 3 AM. He had been following this custom for the last 20 years. According to him, chewing this leaves would provide an aphrodisiac effect, making one feel euphoric and keep awake to socialize with peers of the community until late night. However, due to a recent illness in his sister (who had chronic renal failure), he was busy in care giving for the last 4 months and was not been able to follow the custom of chewing khat leaves in social weekend gatherings. According to him, his symptoms had started after stopping this custom. On examination, he was found to have greenish staining of teeth [Figure 1]. His neurological examination was normal. His contrast enhanced computer tomography head was normal. He was treated with 25 mg/day topiramate, which was increased to 50 mg/day in 10 days along with 10 mg/day of escitalopram along with paraffin syrup for constipation and explained about lifestyle modification. On a follow-up at 3 and 6 weeks, he had significant improvement in his headache episodes as well as mood and other somatic problems.\nOUTPUT:" }, { "from": "agent", "value": "Chronic migraine without aura, anxiety, depression" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: We performed nine reverse sural fasciocutaneous flaps from December 2018 to June 2020. All nine patients were men with a mean age of 38 years old (the youngest was 29 years old and the oldest, 46 years old). Regarding personal medical history, eight patients (88.89%) presented no comorbidities, one (11.11%) presented hypertension, two were smokers, two were alcoholics, one used illicit drugs, and five had no addictions. Table 1 presents epidemiological data and other results. Regarding the etiology of injuries, five patients (55.56%) were victims of car accidents, three (33.33%) presented post-traumatic chronic wound, and one (11.11%) was a victim of electrical trauma. Regarding the injury time, five patients (55.56%) presented acute wounds (less than 30 days between trauma and reconstructive surgery), and four (44.44%) presented chronic wounds (more than 30 days). The other patients (83.33%) presented injuries in other body segments. Regarding the injury site, six patients (66.67%) injured the ankle, two (22.22%) injured the foot, and one (11.11%) injured the calcaneus. We analyzed technical details of the surgery: all reverse sural fasciocutaneous flaps were pedicled; the mean surgery time was 160 minutes (the quickest surgery lasting 80 minutes and the longest, 220 minutes); five donor areas were treated with skin graft (55.56%) and four of them, with primary closure (44.44%). During the postoperative follow-up, four patients presented complications (44.44%): three of them presented distal necrosis and one presented distal epitheliosis. We observed no total loss of the flap. The mean length of hospital stay was 30.1 days (minimum stay of five days and maximum stay of 57 days).\nOUTPUT:" }, { "from": "agent", "value": "Lower limb injuries" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: 1 , panel A) arising from the circumflex artery (CX) had already been described, but at that time, no further action had been taken. Now, more than 10 years later, the patient returned with exertional dyspnea and again underwent coronary angiography. Since he was symptomatic, but his lesions did not appear flow limiting, interventional closure of the fistula was considered, but a CT angiography of the chest was performed to further evaluate the fistula and its target vessel or chamber. His chest CT showed a smaller left and larger right hemithorax together with fibrotic and emphysematous changes of the left lung ( Fig. 1 , panel B). 1 , panel B). 1 , panels C and D) ensured left lung tissue supply. In addition, it revealed a right descending thoracic aorta. Detailed history revealed dyspnea since childhood which led to discharge from military service later in life due to hemoptysis induced by maximum strength exercise. The decision for conservative treatment was made.\nOUTPUT:" }, { "from": "agent", "value": "Coronary Artery Fistula, Absence of Left Pulmonary Artery" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 32-year-old Nepali gentleman presented to Hamad General Hospital in Qatar with a two day history of hematochezia (three bouts of moderate amount of blood in stools). He had no history of diarrhea, abdominal pain or weight loss. General physical examination revealed mild pallor. His hemogram revealed hemoglobin of 9.0 g/dl, total leucocyte count of 3200/mm3, absolute neutrophil count of 2100/mm3 and platelet count of 42000/mm3. His liver function test (LFT) showed mildly elevated alkaline phosphatase (ALP = 313, normal < 129I U/L), aspartate transaminase (AST = 132, normal < 40 U/L), alanine transaminase (ALT = 83, normal < 40 U/L) and normal bilirubin and albumin levels. Ultrasound of the abdomen was unremarkable. His tests for dengue serology and viral markers (IgM Anti Hbc, IgM anti HAV, IgM anti HEV) were negative. During his hospital stay, the patient developed two more bouts of massive hematochezia and his hemoglobin dropped to 5.9 g/dl. He was resuscitated with intravenous fluids and packed red blood cell transfusion and underwent emergency colonoscopy. He was empirically started on ceftriaxone. An ulcer with a spurt of blood was seen in the terminal ileum and a few small ulcers in the ileocecal valve and terminal ileum. The active gastrointestinal bleeding was managed with hemoclips and epinephrine injection. The patient did not have further episodes of hematochezia and subsequently improved over the hospital stay. He completed a seven day course of ceftriaxone and was discharged from hospital with hemoglobin of 12 g/dl. His pancytopenia resolved. A follow up liver function test after two weeks was normal and the patient remained asymptomatic up until the last follow-up.\nOUTPUT:" }, { "from": "agent", "value": "Enteric fever" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 60-year-old female presented to emergency services (ER) reporting a 6-hour history of myalgia, suprapubic pain, and febrile morbidity (38.9 C/102 F). The patient was considered to be of her normal state of health prior to the onset of symptoms. Her gynecologic history was noncontributory and her medical comorbidities consisted of stable hypertension and chronic obstructive pulmonary disease. Initial significant physical examination findings and laboratory results were as follows: lower abdominal pain without rebound or guarding and leukocytosis (WBC 22,000/mm3 and 39% bands). Within 6 hours after admission, the patient complained of increasing abdominopelvic pain and developed clinical signs of sepstic shock. Intravenous gentamycin and clindamycin were added to the antimicrobial regimen, and the patient was transferred to the medical intensive care unit (MICU). Computed tomography (CT) revealed normal abdominal anatomy except for a uterus measuring 21 cm x 16 cm with fluid within the endometrial cavity and multiple leiomyomas (no evidence of myometrial gas). Gynecology was consulted and further examination confirmed a pelvic mass with suprapubic and cervical motion tenderness. After bedside endometrial biopsy was unable to be performed secondary to cervical stenosis, an ultrasound-guided transvaginal endometrial biopsy was performed as previously described. The patient's condition continued to worsen and clinical management was complicated by the development of anemia, hyperbilirubinemia, hemoglobinemia, hemoglobinuria, and hypotension requiring blood transfusion and vasoactive support. Gram stain of the intrauterine fluid revealed gram-positive rods. Intraoperative findings revealed an enlarged fibroid uterus with inflammatory changes involving the uterine serosa, no evidence of tubo-ovarian abscess or infection involving the extrauterine structures. Postoperatively, the patient recovered fully after 4 days of MICU support and 13 days of hospitalization. Final culture of blood and intrauterine specimens revealed Clostridium perfringens.\nOUTPUT:" }, { "from": "agent", "value": "Clostridial sepsis, Degenerating uterine leiomyoma" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 71-year-old Caucasian man had been experiencing abdominal distension, nausea, and vomiting for three months. His symptoms worsened progressively over the previous two weeks when he was referred to our institution for further evaluation. The abdominal distention and vomiting appeared to be mostly postprandial, and the vomitus consisted of mainly undigested food and no bile. His symptoms were independent of the type and consistency of the type of the food ingested. His past medical history was significant for cardiovascular diseases, end stage renal disease, and diabetes mellitus with no history of gastrointestinal problems. Abdominal films obtained before admission showed massive gastric distension. Physical exam revealed a soft, mildly distended abdomen. No tenderness, mass, and/or hernia were discovered. The remainder of the examination was unremarkable except for his dialysis fistula in right upper extremity. He was admitted with diagnosis of gastric outlet obstruction. Abdominal films following admission again demonstrated gastric distension with air fluid levels. A CT scan did not show any evidence of extrinsic compression. An upper endoscopy (EGD) demonstrated massive gastric distension with a large collection of partly digested food. There was no evidence of an ulcer or other mucosal defect in the pyloric channel, but the channel did not appear to relax and dilate (Figure 1(a)). The duodenum was unremarkable. The patient did not improve, and surgical exploration was recommended. At exploratory laparotomy, a massively dilated stomach was encountered. During this procedure, a minigastrotomy was made on the greater curvature of the stomach, and greater than 3 liters of foul-smelling particulate matter gastric contents were removed, consistent with longstanding food retention. An antrectomy with Roux-en-Y gastrojejunostomy was performed, and a Witzel feeding jejunostomy tube was placed.\nOUTPUT:" }, { "from": "agent", "value": "Idiopathic hypertrophic pyloric stenosis" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A healthy 25-year-old female presented with a pruritic eruption on the right upper extremity of 6-year duration. There was no disease in childhood. The lesions appeared to follow lines of Blaschko, with progression to the shoulder and mid-scapula during 5 months of observation (Figure 1(a) and (b)). The patient described worsening of symptoms with sun exposure. The remainder of her examination was normal. No acantholysis was noted. A skin biopsy revealed distinctive cornoid lamellae comprising thin, columnar, closely stacked, parakeratotic cells extending through the stratum corneum with a minimal granular layer (Figure 2). A therapeutic trial of isotretinoin 1.5 mg/kg for 24 weeks (6 months) and 1.7 mg/kg for 8 weeks (2 months) resulted in dramatic regression of hyperkeratotic changes, although mild local hyperpigmentation remained at the 2-month follow-up (Figure 3). The patient provided informed consent to publish her unique case findings.\nOUTPUT:" }, { "from": "agent", "value": "Linear porokeratosis" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 4-year old boy presented with swelling in the right lower abdomen for the last 31/2 years. Swelling was not associated with pain and gradually increased in size as the child grew. Mother gave history of gurgling sound on pressing the swelling. On general examination, the child was pale. There was a non-tender abdominal distention in right iliac region. Child was admitted twice for sub-acute intestinal obstruction and was managed conservatively. Ultrasound revealed a cystic mass lesion in right iliac fossa extending to right flank with internal calcification and was reported as neuroblastoma. USG was repeated which reported dilated bowel loops. MRI was done and revealed large distended bowel loop in right iliac fossa measuring 6.5 cms in diameter with residual food particles and air-fluid levels, suggestive of partial cecal volvulus. There was also a defect seen anteriorly at the level of D12-L1 with prolapsed cerebrospinal fluid filled pouch with few neural components in the abdominal cavity (Fig.1). Both the testes were seen in abdominal cavity. In view of partial cecal volvulus, barium meal study was done, which showed small bowel malrotation with large cavity communicating with ileal loop, suggestive of ileal duplication cyst. (Fig.2) Resection of the dilated segment with end-to-end ileo-ileal anastomosis along with excision and repair of AMC were done. The biopsy showed normal bowel musculature with mild mucosal edema, submucosal vascular congestion, serositis, and presence of normal ganglion cells in both the plexi.\nOUTPUT:" }, { "from": "agent", "value": "Segmental dilatation of ileum, anterior thoracolumbar meningomyelocele, bilateral undescended testes" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 17-year-old previously healthy mixed-race male was transferred to our pediatric wards for respiratory distress in late April 2020. He presented with 5 days of fever, cough, post-tussive emesis, dyspnea, pleuritic chest pain, myalgia, and decreased appetite. When his symptoms first started, he had gone to the ED where he was diagnosed with community-acquired pneumonia and prescribed amoxicillin. He returned to the ED with worsening symptoms and was found to be febrile to 39.1 C, tachycardic (HR: 90-133 beats/min), and tachypneic (RR: 26-32 breaths/min) with hypoxemia (SpO2: 85%), raising suspicion for COVID-19. On initial exam, he was noted to be in significant respiratory distress with bilateral diminished breath sounds and coarse crackles. The laboratory findings were remarkable for elevated WBC with neutrophilia, elevated inflammatory markers, negative SARS-CoV-2, RVP, and blood cultures (Table 1). His CXR showed bilateral perihilar and bibasilar consolidative patchy opacities, more on the left side, with diffuse prominence of the reticular pattern (Figure 1). His respiratory distress quickly worsened, and he required PICU level of care for NIPPV and eventual intubation. He was started on azithromycin, ceftriaxone, and vancomycin for community-acquired pneumonia. A bronchoscopy performed by the pulmonary service on day 2 of hospitalization showed moderate-to-severe airway inflammation, a neutrophil predominant BAL sample and negative cultures. His CT chest demonstrated diffuse alveolar ground glass opacities throughout the lungs with prominent subpleural sparing, septal thickening, bilateral small pleural effusions, and bibasilar dependent consolidation (Figure 2). The patient was started on 7 days of methylprednisolone 1 mg/kg twice daily due to high suspicion for EVALI. The patient was able to be extubated after 5 days of corticosteroids and was discharged home on fluticasone/salmeterol 115-21 mug twice daily with recommendation for close follow-up with his primary care physician and pulmonologist.\nOUTPUT:" }, { "from": "agent", "value": "E-cigarette, or vaping, product use-associated lung injury" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 64-year-old man was first diagnosed with HS 28 years ago, following a 3-year history of painful furuncles in the axillary and gluteal regions that were unsuccessfully managed with oral antibiotics and multiple incision and drainage procedures. Comorbidities included diabetes managed with twice daily metformin, dyslipidemia, and hypertension. Adalimumab (a human monoclonal antibody against TNF-alpha) in 40 mg per week subcutaneous injections effectively improved symptoms and reduced the size of the nodules. After 2 years of therapy, the patient presented with a 14 cm x 10 cm ulcerated exophytic tumor in a HS-affected area involving the left buttock and intergluteal cleft. The biopsy specimen revealed a low-grade well-differentiated SCC, and surgical excision of the lesion was performed at the community hospital. As surgical margins were incomplete, the patient was referred to our tertiary care surgical oncology service for re-excision. The tumor proved to be highly aggressive as within 2 months a new violaceous necrotic mass had rapidly emerged within the surgical wound (Figure 1). This time, an extensive surgical resection extending to the deep fascia was performed (Figure 2). Post-operative wound care with vacuum assisted closure (VAC) therapy and pain management with oral analgesics allowed for a rapid recovery. Pathological examination of the surgical specimen revealed a markedly more aggressive and undifferentiated tumor than what was observed 2 months prior upon first resection at the community hospital. Indeed, microscopy now showed an infiltrating poorly differentiated SCC composed of islands of atypical sarcomatoid spindle cells (Figure 3), staining positive for CK5/6, CKAE1/AE3, p63, and vimentin. Numerous mitoses were noted. Melanoma was ruled out as S100, and Melan-A were negative. CD34, CD31, desmin, and p16 were also negative. There was no vascular or lymphatic invasion. Surgical margins were positive at the level of the intergluteal cleft, and a third resection was scheduled. Unfortunately, the patient died shortly after from pulmonary metastases.\nOUTPUT:" }, { "from": "agent", "value": "Cutaneous squamous cell carcinoma, Hidradenitis suppurativa" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 31-year-old male fell from a balcony approximately 40-50 feet height. On admission with a GCS score of 5, he was unable to move his extremities and had no rectal tone. The patient underwent emergent posterior spinal decompression with fusion from C4 to T2. Postoperatively, the patient was monitored closely in the ICU. He had upper extremity function but appeared plegic in the lower extremities without sphincter tone.\nOUTPUT:" }, { "from": "agent", "value": "Bilateral cervical facet dislocations at C6/C7 and C7/T1, Grade 1 anterolisthesis at C7/T1, injury to the C6/C7 and C7/T1 ligaments, severe canal narrowing, high intramedullary cord signal/edema, C5-T1 epidural hemorrhage, diffuse axonal injury, bilateral pedicle fractures at C7, lateral mass fracture at C7, severe brain injury." } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 23-year-old male with past medical history of asthma and remote substance abuse presented with a new onset of seizures. Initial history was provided by Emergency Medical Services (EMS) and family members. The patient was lying in bed vaping and talking on the phone when he spontaneously began experiencing seizures. It was unknown how long the patient was convulsing prior to being found by his family. Midazolam was administered by EMS upon their arrival, which halted the seizures. When the patient arrived in the emergency department, he was tachycardic (134 BPM), tachypneic (RR 25), and hypoxic, requiring a non-rebreather mask to maintain appropriate oxygen saturations. He was afebrile. Physical exam was pertinent for altered mental status and inability to follow commands, subcostal retractions, and diffuse rhonchi on respiratory auscultation. A rapid arterial blood gas showed respiratory acidosis. The patient was intubated for airway protection. Initial laboratory results showed a leukocytosis of 19.4 cells per microliter and a creatinine of 1.69 milligram per deciliters. Computed tomography (CT) of the brain was unremarkable. The patient appeared to meet criteria for sepsis on admission. However, no infectious etiology was identified. This included blood cultures, cerebral spinal fluid cultures, and viral tests for human immunodeficiency virus, hepatitis, COVID-19, and influenza A and B. The patient was extubated one day after intubation. Electroencephalogram was unremarkable for active seizures. The patient was treated with levetiracetam and was free of seizure activity for the remainder of his hospitalization. The patient's renal function improved with intravenous fluids and the patient was discharged on day five of admission.\nOUTPUT:" }, { "from": "agent", "value": "Bilateral Upper Lobe Collapse Secondary to Vaping, Systemic Inflammatory Response Syndrome" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: An 89-year-old non-smoker woman with a significant past medical history of interstitial lung disease, congestive heart failure with 15% ejection fraction, non-ST-elevated myocardial infarction, hypertension, cerebral vascular accident 6 years ago with complete recovery, deep venous thrombosis (DVT) 4 years ago with s/p inferior vena cava filter, presented to the hospital with a chief complaint of painful right-sided facial swelling. Her facial swelling started 2 days prior to admission, accompanied by erythema around the cheek, which was painful. The erythema eventually progressively spread all over the right side of her face and involved the mucus membranes in the oral cavity. The patient denied any fever, cough, flu-like symptoms, injury to the area, headache, visual disturbances, or recent contacts with the sick. On physical examination, the right side of face was diffusely swollen, erythematous, and indurated. There was no softening or fluctuation, but it was tender with a 2.4 x 1.6 cm scab noticed on the right upper lip. The right side mucus membrane in the oral cavity was swollen and erythematous without any ulcers. Methicillin-resistant Staphylococcus aureus (MRSA) was identified from blood cultures. The patient was treated as an inpatient for cellulites with intravenous antibiotics as per sensitivities, which produced only partial improvement after 3 weeks. Oral cavity erythema was completely cleared. However, the right infra-orbital erythema and the mild swelling were persistent after 3 weeks of intravenous antibiotics treatment. Therefore, an underlying skin disease was suspected and punch biopsy was taken from the lesion covered by a scab on the right upper lip (Fig. 1) and sent for histopathological examination. Biopsy of the lesion confirmed grade 1 (well-differentiated) SCC, not otherwise specified. CT of the neck with contrast did not reveal any lymph node metastasis. The patient was referred for elective surgical excision, which she refused to have.\nOUTPUT:" }, { "from": "agent", "value": "Skin squamous cell carcinoma" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: He lost 3 kg in body weight over a period of six months. He underwent one course of systemic chemotherapy (cisplatin at 80 mg/m2 and docetaxel at 60 mg/m2 on day one). He was treated prophylactically with dexamethasone and granisetron for antiemesis just before the chemotherapy. From day three to day 10 after the initiation of chemotherapy, he had anorexia, nausea and vomiting, estimated as grade three according to the common terminology criteria for adverse event, Version 4, and lost 4 kg in weight. On day 17, he presented with epigastric pain and vomiting. Physical examination showed a distended abdomen and decreased bowel sound. Plain abdominal X-ray showed a distended stomach and duodenal gas (Figure 1). Contrast-enhanced abdominal computed tomography (CT) showed a distended stomach and duodenal bulb due to compression of the third portion of the duodenum, an aortomesenteric distance of 6.1 mm (normal: 10 to 28 mm) and a reduction of the aortomesenteric angle to 15.8 (normal: 25 to 60 ) (Figure 2). These findings were highly suggestive of SMA syndrome. An upper gastrointestinal series in the supine position showed a sharp cut-off at the third portion of the duodenum (Figure 3A). In the prone position, the contrast medium passed through the obstructed part of the distal side of the third portion of duodenum (Figure 3B). After inserting a nasogastric tube, more than 2700 mL turbid, green fluid was drained. His symptoms improved after nasogastric tube drainage and he remained in the prone position. The patient was given total parenteral nutrition for 10 days and tubal feeding for the following 10 days. After 20 days, his body weight increased from 45.6 to 49.0 kg and he returned to oral intake without subsequent symptoms. Subsequent chemotherapy using the same regimen was started after his body weight reached more than 50 kg. He presented with grade 2 emesis during chemotherapy but developed neither SMA syndrome nor weight loss. A total of four cycles of chemotherapy were performed, and the patient achieved a partial response.\nOUTPUT:" }, { "from": "agent", "value": "Superior mesenteric artery syndrome, Stage IIIB squamous cell carcinoma of the lung" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: The SLIT dosage regimen of the current case was initiated as one tablet a day (ACARIZAX 12 SQ-HDM, Dermatophagoides pteronyssinus and Dermatophagoides farinae 50%/50%; ALK-Abello, Horsholm, Denmark) for a planned 3 years. A 35-year-old male with known allergic rhinitis due to HDM (Dermatophagoides pteronyssinus specific IgE 11 x 103 IU/L), diagnosed using a radioallergosorbent test, received the first tablet (ACARIZAX 12 SQ-HDM) at an outpatient facility. The dose was held sublingually for 1 min before any swallowing was permitted. The treatment was performed in the morning. During the first few minutes, only discrete oropharyngeal itching was present. After 30 min, the itching had subsided. However, 1 h post treatment, a debilitating right-sided, high-frequent, subjective buzzing noise with constant intensity started. The sound was independent of position of the head. There was no concomitant hearing loss. No exposure to loud, high noises was reported, and there was no history of use of portable music devices. The patient had not suffered from any recent respiratory tract infections, taken any concomitant medication, or experienced any head and neck traumas. There were no psychiatric disorders or stress-related complaints. Furthermore, no temporomandibular joint problems were present. The patient had an examination at the Department of Ear, Nose, and Throat after symptom duration of 24 h, but no pathology was revealed. Hence, no obvious reason for the symptoms was found. A review of his prescriptions showed great compliance to SLIT.\nOUTPUT:" }, { "from": "agent", "value": "Tinnitus" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: The tumour was predominantly well differentiated with smaller areas showing poorly differentiated tumour cells. The tumour was excised completely but the closest posterior margin was only 1 mm. Following referral to our institution, postoperative radiotherapy was delivered to the chest wall using a single 8 Mev electron field, delivering 40 Gy in 15 fractions over 3 weeks followed by an electron boost to the scar of 10 Gy in 4 fractions. A subsequent CT scan showed multiple bilateral lung nodules considered too numerous to consider metastectomy. Due to the patient's poor general fitness, she was not a candidate for chemotherapy but was kept on regular follow-up. Over the next few months, she developed symptoms of disease progression and the repeated chest X-rays showed an increase in the size and number of lung nodules (Figure 2). Physical examination at that time also revealed multiple new subcutaneous nodules on her scalp consistent with metastatic skin deposits. As these nodules were not causing her any symptoms, no palliative treatment was offered at that time. She was reviewed again in the clinic in December 2007 and commented that the scalp nodules had regressed. On clinical examination, the subcutaneous scalp nodules were no longer palpable and a subsequent chest X-ray showed a reduction in the number and size of lung nodules. The patient denied taking any nonprescribed medication or dietary change leading to the conclusion that this represented a spontaneous regression (Figure 3).\nOUTPUT:" }, { "from": "agent", "value": "Breast Angiosarcoma, Pulmonary Metastases" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 70-year-old-man consulted for epigastric pain and dyspepsia symptoms. His past medical and surgical history included obesity (BMI: 53.9 kg/m2), hypertension, hyperlipidemia, diabetes mellitus type 2, cardiac failure and a surgical treatment with laparoscopic gastric banding 12 years before. After the first postoperative year, despite numerous telephone calls, the patient did not show up for follow-up visits. Ten years later, the patient returned with weight regain. Thus, for the analysis and control of the gastric banding, an upper gastrointestinal endoscopy was performed evidencing many small polyps in the gastric antrum, body and fundus (only at the greater curvatures). Laparoscopic surgery for the removal of the gastric banding which was found to be correctly positioned and the subtotal gastrectomy leaving a small gastric remnant of approximately 2-cm in size similar to the pouch of a bypass was done. Roux-en-Y reconstruction was performed with 100 cm of the biliary loop and 100 cm of alimentary loop. Due to the histological type, size and extension depth of the lesions lymphadenectomy was not considered. There were no complications following surgery. The first 24 h the patient remained in the intensive care unit where he was started on oral infusions then he was referred to the general ward to be discharged 72 h postoperatively. Histopathological evaluation confirmed well-differentiated stomach neuroendocrine carcinoma with resected margins and an invasion up to the gastric submucosa. Twelve months after surgery the patient presented a body mass index of 36.6 kg / m2 with doses reduction of oral hypoglycemiants and minimum requirements of medication for his cardiovascular disease.\nOUTPUT:" }, { "from": "agent", "value": "Gastric carcinoid tumor" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 38-year-old female with a history of a multinodular goiter, hyperthyroidism, and iodine allergy presented to the emergency department complaining of palpitations, chest discomfort, and dyspnea. The patient reported that she had recently restarted taking methimazole 10 mg daily after being noncompliant with her medications for the past 3 years. In the emergency department, she was found to be in atrial fibrillation with a rapid ventricular rate and to have an estimated left ventricular ejection fraction of 20%. Laboratory evaluation revealed a suppressed thyroid-stimulating hormone (0.01 mlU/L), elevated free T4 (3.48 ng/dL), elevated free T3 (9.90 pg/mL), and normal liver transaminases. A diagnosis of thyrotoxicosis was made, and treatment with PTU and propranolol was initiated. PTU was chosen due to its inhibition of the peripheral conversion of T4 to T3 and subsequent preference in thyroid storm. Nine hours after the initial dose of 200 mg PTU, the patient's aspartate aminotransferase and alanine aminotransferase levels showed significant elevation, eventually peaking at 1127 IU/L and 1004 IU/L, respectively (Figure 1). The patient was then transferred to the intensive care unit for close monitoring. This initial treatment was followed by the failure of a tapered regimen of methimazole secondary to persistently worsening liver function. Intravenous corticosteroids were initiated, resulting in the improvement of both liver and thyroid functions. This allowed for the reintroduction of methimazole without any observed adverse effects. On discharge, the levels of aspartate aminotransferase and alanine aminotransferase were decreased to 38 IU/L and 163 IU/L, respectively. In addition, cardiac function improved with a recalculated left ventricular ejection fraction of 40%. Her hepatitis panels and an autoimmune workup (anti-nuclear antibody, anti-smooth muscle antibody, and anti-mitochondrial antibody) came back as negative. The patient has since had progressive increases in methimazole doses up to 40 mg daily on an outpatient basis. No evidence of further hepatotoxicity was confirmed by a 1-month follow-up, demonstrating complete normalization of liver enzymes.\nOUTPUT:" }, { "from": "agent", "value": "Drug-Induced Liver Injury" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 26-year-old female had a deceased-donor renal transplantation for the management of end-stage renal disease secondary to Alport syndrome. The induction agent used at the time of transplantation was ATG 4.2 mg/kg. Afterwards, she received immunosuppressive maintenance therapy that consisted of MMF 1000 mg BID, Tacrolimus, and prednisone 5 mg daily. The donor's and recipient's PB19 statuses were unknown. The patient developed severe symptomatic, normocytic, and normochromic anemia (hemoglobin 55 g/L) 6 months after transplantation with normal platelet and white cell count. A complete anemia work-up showed low reticulocyte count; otherwise, inconclusive. Her severe anemia persisted for over 2 weeks despite packed blood cell transfusion, adjustment of immunosuppressant medications, and administration of erythropoietin stimulating agent. PB19 PCR was sent few days after admission and came back positive. MMF was held, and 2 gm/kg of IVIG was given over 4 doses. She was discharged few days after completing the IVIG course with better hemoglobin (90 g/L). The patient was seen after 2 weeks in the clinic with almost normalized hemoglobin (124 g/L). Hence, MMF 500 mg twice daily was restarted. 5 weeks later, the patient presented again to the emergency department with fatigability and shortness of breath and a hemoglobin level of 52 g/L. Another course of IVIG treatment was initiated. She received a total of 2 gm/kg over 4 doses, and MMF was held again. PB19 PCR came back positive yet again. After treatment, she improved and was discharged home. The hemoglobin level normalized after few weeks. Hence, MMF 500 mg BID was restarted. For the third time, the patient represented with severe anemia requiring blood transfusion. She was given IVIG 2 gm/kg again and discharge with a plan to discontinue MMF permanently. Her hemoglobin remained stable during the subsequent 2 years of follow-up with no further relapse.\nOUTPUT:" }, { "from": "agent", "value": "Parvovirus B19 Infection" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 44-year-old Japanese male, an office worker, was transported to our emergency department with a complaint of temporary loss of consciousness. He had experienced fatigue for 3 years and had fallen easily in his daily life starting 2 months before admission. He was feverish and had a cough and phlegm for several days before admission. On the way to work, he felt drowsy and fell down the stairs of the train station, necessitating transport to our hospital by ambulance. The peripheral blood analysis noted mild elevation of white blood cells. The blood chemistry test disclosed mild elevation of C-reactive protein and mild liver dysfunction (Table 1A). He was thin, i.e., his height was 174 cm and he weighed 52 kg (Figure 1). Chest computed tomography (CT) showed severe infiltration in the upper posterior fields of both lungs as well as food debris in the esophagus. He had experienced ileus six times since age 30 years. He was not married. His father had died of dilated cardiomyopathy at the age of 70 and had also been thin. On the other hand, his mother was healthy but his maternal uncle was diabetic. His younger sister (Case 2) also had mild muscle weakness of the four extremities. Electromyography performed to test the biceps brachii muscle and femoral quadriceps muscle on the left side revealed frequent myotonic discharges. Because DM1 was strongly suspected, we recommended that, after providing informed consent during genetic counseling, he undergo genetic testing for DM1 together with his younger sister. The number of CTG repeats in the DMPK gene was abnormally expanded to about 600 repeats in the elder brother and about 900 repeats in the younger sister, in contrast to those of healthy individuals who have 5 to 37 repeats, thereby confirming the diagnosis of DM1 in these siblings (Figure 2).\nOUTPUT:" }, { "from": "agent", "value": "Myotonic Dystrophy Type 1, Aspiration Pneumonia, Diabetes Mellitus" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 50-year-old male patient with pain in the maxillary right first molar and a blackish growth on the right side of hard palate since 12 days visited the Department of Oral Medicine and Radiology. The patient did not report taking medications for any other illnesses. Habitual history was negative. Extra-oral examination revealed enlargement of bilateral submandibular lymph nodes, which were oval in shape, mobile, and nontender. On intraoral examination, a black exophytic growth was seen on the right side of the hard palate (Figure 6). The lesion extended onto the buccal aspect involving the gingiva between the maxillary right first and second molars (Figure 7). It was soft in consistency and nontender. Small satellite lesions were seen on the palate surrounding the lesion. Radiographs were taken and incisional biopsy performed. Orthopantomogram showed carious maxillary right first and second molars with destruction of the interdental bone between them. The continuity of the floor of the maxillary sinus was disrupted in the maxillary right first molar region. The periodontal ligament space in relation to all the right maxillary molars and second premolar was widened (Figure 8). CT scan showed an ill-defined enhancing soft tissue mass on right side of hard palate, extending posteriorly upto the soft palate. There was no evidence of erosion or sclerosis of bone due to the soft tissue mass (Figures 9 and 10). Bilaterally enlarged level I, II, V lymph nodes were seen. Incisional biopsies were taken from both the lesions. Histopathological studies revealed numerous atypical melanocytes within the epithelium and also invasion into the connective tissue. These cells were epitheloid to spindle in shape, with vesicular, hyperchromatic nuclei, and prominent nucleoli. Few mitotic figures were also seen (Figure 11). The patients were then referred to the Regional Cancer Institute for further treatment. Both patients underwent excision of the primary lesion along with radical neck dissection and postoperative radiotherapy.\nOUTPUT:" }, { "from": "agent", "value": "Primary oral malignant melanoma" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: The primary tumor was excised in 2019. Sentinel lymph node biopsy at the time showed positive left axillary node involvement. The patient was treated with wide-margin re-excision followed by adjuvant immunotherapy with nivolumab for one year, ending in February 2020. His positron emission tomography (PET) scan on diagnosis showed mild tracer uptake along the inferior heart border just above the diaphragm and biopsy-proven melanoma. It was felt to reflect the misregistered physiologic activity. Computed tomography (CT) scans of the chest and abdomen during the year of adjuvant treatment reported no concerning findings. The patient remained asymptomatic from a cardiac standpoint. A surveillance PET scan in May 2020 showed a hypermetabolic lesion in the inferior pericardium with a mass effect on bilateral atria. A cardiac magnetic resonance imaging (MRI) was performed for better visualization, which revealed a large 7.8 cm x 3.6 cm irregularly shaped mass in the inferior right atrium adjacent to the inferior vena cava and extending to the interatrial septum (Figure 1). Given the patient's clinical history, the presumptive diagnosis was metastatic malignant melanoma. He was initially referred to an interventional cardiologist and underwent interatrial septal mass endomyocardial biopsy (EMB), which showed no malignant cells. A repeat CT of the chest, abdomen, and pelvis in July 2020 showed no other metastatic melanoma sites. The patient was then referred to thoracic surgery for surgical biopsy and debulking. The tumor's immunohistochemistry staining was only positive for vimentin, which excludes angiosarcoma, metastatic melanoma, and rhabdomyosarcoma. He was started on gemcitabine and docetaxel, but progression was seen at imaging after three treatment cycles. He then started on proton beam radiation with gemcitabine. Post-treatment cardiac MRI in April 2021 showed stable disease. However, a repeat PET scan in July 2021 showed metastatic disease in the brain, pterygoid soft tissue, lung, and mediastinal nodes. The patient decided to pursue hospice care in July 2021 and passed away a few weeks later. Case 2\nOUTPUT:" }, { "from": "agent", "value": "High-grade spindle cell sarcoma" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 52-year old Caucasian female with severe hypoglycemia (insulin requirements 0.53 U/kg/day; A1c of 7.1%; HYPO score 2760; Lability Index of 245) received a single islet infusion of 3801 IE/kg in 2002 with daclizumab induction and sirolimus and tacrolimus maintenance and became insulin independent for 446 days. Autoantibodies against mIAA were strongly positive (500 x ULN) while antibodies against GAD and ICA 512 were both negative. A second infusion (5484 IE/kg) using the same induction and maintenance was given in 2005 resulting in insulin independence for a further 701 days. In May 2007 sirolimus was discontinued due to adverse effects (poor energy, edema and acne) with the addition of mycophenolate mofetil (1000mg po BID initially and then 500mg BID secondary to diarrhea) and an increase in the tacrolimus target range (from 3-6 mcg/L to 8-10 mcg/L). On 20th October, 2009, the patient reported hair loss affecting her scalp and body. Just ten days prior, she had described feeling generally well. Despite stable doses of tacrolimus (2.5mg po BID) her trough levels frequently fluctuated (5.8 - 14.9 mcg/L) possibly as a consequence of diabetic gastroparesis. Tacrolimus levels during this period were sustained above 10mcg/L with highest recorded level of 14.9mcg/L despite no change in tacrolimus dose. She commenced an anthralin cream as recommended by her dermatologist and continued tacrolimus monotherapy with levels stabilized between 7-10mcg/L and lymphocyte count remained > 1x109 throughout. The patient was unwilling to switch to cyclosporine, but reported patchy regrowth of some fine hair and at follow-up in May 2010, patient had <= 25% hair loss remaining.\nOUTPUT:" }, { "from": "agent", "value": "Alopecia" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 33-year-old woman presented at 32 weeks gestation. The cesarean delivery was planned because of cephalopelvic disportion. She had a low back pain and the left-sided leg pain below the knee. There was no motor weakness. On physical examination, straight leg raising test was restricted to 20 . 1). The patient was managed with physical therapy and acetaminophen for the pain. However, at 34 weeks gestation, she had severe weakness of the left extension halluces longus, left ankle dorsiflexion. She had decreased in the L5 nerve root distribution of left lower extremity. 2). We performed cesarean delivery in the supine position before a discectomy in the prone position. Although preoperatively we simulated that the patient really tried to be in some various prone positions on operating table, we found the prone position for discectomy was difficult to achieve with a 34-week gravid uterus. And there were few risks of newborn infant complications with the cesarean delivery at a 34-week. The cesarean delivery was performed with the patient under epidural anesthesia, resulting in the delivery of a normal baby. A healthy male (2569 g) was delivered. The patient was then turned to a prone position, and a left L4/5 discectomy was performed. Neither the patient nor the baby had any complication related to surgery. In the immediate postoperative period, the patient experienced relief of left leg pain. But the day after surgery, she had a severe low back pain and the right leg pain below the knee. 3). She could not walk because of the right leg pain. At 6 days after the first surgery, a right L4/5 discectomy was performed, and a large disk fragment that had displaced into the spinal canal was removed. In the immediate postoperative period, the patient experienced complete relief of the right leg pain. After all operations, MRI showed herniation was disappeared (Fig. 4). At 18 months follow up after the last operation, she had a numbness and a slightly weakened dorsiflexion on the left extremity. The trouble is not observed in activities of daily life.\nOUTPUT:" }, { "from": "agent", "value": "Lumbar disk herniation" } ]