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: Patient #045 (pt-045) is a 51 year-old Caucasian man, to whom in January 2016 a primary dorsal epithelioid CM (1 CM) was excised. Its main characteristics were a 2.3 mm Breslow thickness, an intermediate proliferative index (23% Ki-67+), and non-brisk lymphoid infiltration; no evidence of ulceration, regression, satellitosis, or vascular invasion were found (Supplementary Figure 1). One month later, a right axillary sentinel lymph node (LN) was excised, and a micrometastasis was found. Pt-045 was therefore at stage-IIIA (AJCC 8th edition), but radical lymphadenectomy was not performed. In April 2016, the patient signed the informed consent and entered the CASVAC-0401 study, being assigned to the CSF-470 vaccine arm. In August 2016, after receiving four vaccinations, a CM recurrence on the scar (Scar-CM) was excised, which displayed scarce CD8+ lymphocyte infiltration (not shown). The patient continued treatment as per protocol. A radical axillary LN resection and a C-MTS was resected; 1/20 metastatic LN was found. In the same surgical procedure, three vaccination nodules (VAC-SITE), all metabolically active, were excised at the patient's decision. After surgery, pt-045 continued and completed the 2-yr immunization protocol with the CSF-470 vaccine without further events, and without evidence of disease 36 months from protocol start. In the present study, one VAC-SITE and the C-MTS were analyzed in detail. Time course of treatment, as well as the surgical events and blood extractions, are indicated (Supplementary Figure 2).\nOUTPUT:" }, { "from": "agent", "value": "Cutaneous 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: A 63-year-old female with hypertension, obesity, and a remote history of bilateral total knee arthroplasty (TKA) presented with chronic right knee pain. She previously required right TKA explant with dynamic spacer placement three years prior to presentation due to joint failure. These operative cultures were negative. Physical examination revealed a small area of swelling over the medial right knee without erythema or warmth. There was mild pain with range of motion and weight-bearing. Vital signs were normal. An ultrasound-guided aspiration of the right knee yielded sanguinopurulent fluid. Fluid analysis showed 98,721 white blood cells per microliter (98 % neutrophils and 2 % monocytes), 168,000 red blood cells per microliter, and no crystals. CBC and CMP were unremarkable. ESR was elevated at greater than 130 millimeters per hour. CRP was elevated at 9.51 milligrams per deciliter. The patient underwent irrigation, debridement, and dynamic spacer explant with placement of a new static antibiotic spacer and knee-spanning intramedullary nail. Multiple synovial fluid and operative tissue cultures grew an AFB on post-operative day five. She was empirically started on amikacin, cefoxitin, and minocycline for coverage of rapidly growing NTM. Based on limited susceptibility, amikacin, omadacycline, and clofazimine were planned for nine months. Amikacin was stopped due to ototoxicity. Ultimately, she required an above-knee amputation of her right lower extremity due to persistence of pain and inability to tolerate antimycobacterial regimen. This case highlights the prolonged duration of illness and indolence due to NTM periprosthetic joint infections (PJI). Furthermore, it demonstrates the multi-drug resistant nature of M. abscessus, difficulty in tolerating therapy, and ultimate morbidity requiring amputation despite prosthetic explantation.\nOUTPUT:" }, { "from": "agent", "value": "Mycobacterium abscessus 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: He was admitted to hospital with a progressive story of four months of constipation, palpitations, headache, dyspnea and sweating. Physical examination revealed a thinned man with peripheral cyanosis, clubbing and signs of decompensated congestive heart failure as hepatomegaly, legs edema, multifocal systodiastolic murmurs, abdominal distension and jugular venous distention. The echocardiogram shows severe right ventricular dysfunction and severe pulmonary hypertension. Furthermore, abdominal computed tomography shows right adrenal mass. Surgical removal is decided and preoperative management begins with alpha-adrenergic blockade, however the patient had a hemodynamic decompensation with an unfavorable evolution. Several studies show a significant association between both of them due to chronic hypoxia leads sustained hyperresponsiveness in adrenal medulla and it would cause the tumor. Image Caption and Description: \nImage caption: []\nImage description: []\nCase Report: \nA 29-year-old Peruvian patient presented to the hospital with progressive history of constipation, bloating and oppressive abdominal pain in the left upper quadrant for 4 months. Then, 1 month ago middle effort dyspnea, palpitations, orthopnoea and sweating were added. The last 15 days appear headache and bilateral lower limb edema, further exacerbation of previous symptoms, so hospitalization is decided.\nOUTPUT:" }, { "from": "agent", "value": "Tetralogy of Fallot, Pheochromocytoma, Situs inversus totalis" } ]

[ { "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 59-year-old female with a known history of obstetric antiphospholipid syndrome, hypertension, and dyslipidemia presented to the emergency department (ED) complaining of headache, fatigue, and abdominal pain. She had recently been diagnosed with bacterial gingivitis, for which a short course of amoxicillin-clavulanate brought no improvement. One month prior to the patient's presentation, her daughter was diagnosed with COVID-19, to whom she was exposed at that time. Several days post-exposure, the patient suffered from an episode of malaise, ageusia, and anosmia. She was not tested for COVID-19 at that time, and a nasopharyngeal swab PCR was negative for SARS-CoV-2 at the time of her admission. Physical examination showed remarkably swollen and erythematous gums (Figure 1(c)), as well as prominent tenderness over the sinuses and epigastrium. Blood tests revealed mildly elevated liver enzymes, increased amylase, marked leukocytosis, severe anemia, and high CRP and ESR. Additional tests were notable for positive c-ANCA, significantly elevated IgG4 levels, and low haptoglobin (Table 1). A peripheral blood smear was normal. Considering vasculitis, a gingival biopsy was obtained, displaying fibrinoid necrosis, with no lymphoplasmacytic infiltrate or IgG4 staining. Full-dose anticoagulation with enoxaparin was also initiated. The latter necessitated the re-administration of a methylprednisolone pulse. In addition, RTX was used for induction of remission. A few weeks following the index admission, SARS-CoV-2 serology returned positive.\nOUTPUT:" }, { "from": "agent", "value": "GPA, Complicated acute pancreatitis, Right subsegmental pulmonary embolism, Right scleritis, Right ear mixed hearing loss" } ]

[ { "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: 62-year-old white man with a past medical history of chronic bronchitis, former tobacco use with 80 pack years of smoking, alcohol use, and incompletely treated pulmonary aspergillosis initially presented with throat pain and odynophagia. Initial chest CT demonstrated multiple subcentimeter lung nodules with subsequent PET scan showing a new 3.2 x 3.1 cm confluent opacity with surrounding ground-glass attenuation at the posterior right lower lobe. He was treated with radiation and 6 weeks of weekly cisplatin therapy. Imaging surveillance was planned for the pulmonary lesions as there was concern for possible metastatic disease. A year later a new irregular, pleural based hypermetabolic right middle lobe nodule was discovered, but not biopsied due to resolution on imaging performed at the time of planned biopsy. Three years later CT acquired for persistent cough demonstrated a stable right upper lung opacity with areas of cavitation and bronchiectasis as well as areas of tree-in-bud nodularity (Fig. 2a). He was treated with guideline-based therapy including rifampin, ethambutol, and isoniazid daily with clearance of sputum cultures. Two years later a repeat CT scan demonstrated increase in opacity in the lateral basilar segment of the left lower lobe (Fig. 2b). He had complained of a productive morning cough and weight loss, but no night sweats, hemoptysis, or fatigue.\nOUTPUT:" }, { "from": "agent", "value": "Stage III moderately differentiated squamous cell carcinoma of the glottis, Mycobacterium kansasii infection, Adenocarcinoma of lung origin" } ]

[ { "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 no history of diabetes mellitus or preceding upper respiratory tract infection. Raynaud phenomenon and dysphagia were not noted. The pain and stiffness in the lower lumbar region and buttock had begun since the age of 24 yr and had been worse in the morning and improved with activity. Physical examination disclosed a symmetric woody induration of the skin on the face, neck, shoulders, trunk, arms, and legs (Fig. 1). His hands and feet were spared. Facial expression was lost: however, the tongue was not enlarged and the frenulum of the tongue was normal. There were no nodules in the skin. In addition, there was marked restriction of lumbar and cervical spine movements. The chest expansion at the fourth intercostal space and modified Schober test were 3.5 cm and 2 cm, respectively. Otherwise, the remaining physical examination was unremarkable. The blood counts, ESR, calcium, urinalysis, glucose tolerance test, and antistreptolysin O titer were normal. There were no abnormalities in chemistry except that the ratio of albumin vs. globulin was reversed, as albumin 3.7 g/dL vs. globulin 4.4 g/dL. Antinuclear antibody was negative, and HLA-B27 was positive. The IgA level was elevated to 2,084 mg/dL (normal, 70-400): IgG and IgM values were normal. Bence-Jones proteinuria was absent. Bone marrow examination revealed no evidences for multiple myeloma. Radiology of the spine and pelvis showed features of advanced AS, including near total ankylosis of bilateral sacroiliac joints and a bamboo spine appearance (Fig. 2). There were no osteolytic lesions on the skeletal survey. Histology of a skin biopsy taken from the arm revealed normal epidermis and a markedly thickened dermis. The collagen bundles were thickened and separated from one another. Alcian blue stain demonstrated abundant mucin deposits between collagen bundles (Fig. 3). After the nature and clinical course of the disease were explained, the patient refused to undergo further treatment, except for nonsteroidal anti-inflammatory drugs.\nOUTPUT:" }, { "from": "agent", "value": "Widespread scleredema, Monoclonal gammopathy, Advanced ankylosing spondylitis" } ]

[ { "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 male subsistence farmer was admitted in the Cardiology unit of Rajshahi Medical College Hospital with recurrent palpitation, atypical chest pain, dizzy feeling and occasional presyncope that aggravated during last 1 year especially on exposure to hot environment. He had no history of night terror or agonal respiration. 1A and B). There is no history of sudden death in his family. His physical examination was unremarkable and serial ECGs remained the same. He was a heavy smoker but nondiabetic, normolipidaemic with normal electrolyte and cardiac enzyme level. His chest X-ray and echocardiogram were normal and coronary angiogram revealed normal coronaries. 2). Both father and the son were advised for regular follow up. Avoidance of precipitating drugs, hot environment, emotion, excitement and prompt use of antipyretic in fever was stressed. Considering symptoms, ECG changes and genetic test result ICD was indicated but patient could not afford it due to high cost involved.\nOUTPUT:" }, { "from": "agent", "value": "Brugada 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 59-year-old male patient came to the emergency department complaining of diffuse musculoskeletal pain. This patient suffered from oesophageal cancer, with metastasis in both lungs, liver, and bones, hence the diffuse pain. He was administered palliative analgesic treatment and was feeling better, getting ready for discharge. The past month, he was admitted to another hospital with shortness of breath, and after an initial negative PCR SARS-CoV-2 test, he was found positive to the virus and was treated according to national protocols, with remdesivir and dexamethasone. During his home stay, he recalled no signs of infection or any clinical syndrome, apart from the intermittent diffuse pain that he had, due to his underlying illness. At the emergency department of our hospital, he wasn't complaining of any respiratory distress, he had normal temperature and the rest of his vital signs and laboratory tests were unremarkable, apart from mild thrombocytopenia. Because of the recent history of SARS-CoV-2 infection, and despite having already 2 negative PCR tests, increased alertness led us to carry out 2 additional SARS-CoV-2 PCR tests, which were also negative. During the second day of hospital stay, though, and having received only analgesic treatment, he developed sudden respiratory distress, with productive cough. His temperature raised to 38 C, while he had low blood pressure and low arterial oxygen saturation. At auscultation fine crackles could be detected bilaterally at lower chest areas. His chest X-ray revealed new diffuse consolidations, compared to the previews day and he developed lymphopenia, and increased C-reactive protein levels (Table 1). Two new oropharyngeal PCR tests SARS-CoV-2 were performed which came back positive. The patient died of respiratory failure the same day. The timeline of events in our patient is illustrated in Figure 1.\nOUTPUT:" }, { "from": "agent", "value": "SARS-CoV-2 Clinical Relapse" } ]

[ { "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: FNAC was inconclusive. Hence, lumpectomy was planned and intraoperative frozen section diagnosis was requested. The resected tumor measured 2.0 cm x 1.5 cm x 1 cm in size and was well circumscribed, firm and grayish-white with a glistening appearance. Frozen section revealed a spindle-cell tumor with a benign appearance. There was focal nuclear enlargement and presence of focal infiltration into the adipose tissue, but mitotic activity and necrosis were not seen. In view of a predominantly well-circumscribed mass with a benign histology, a diagnosis of benign spindle-cell tumor was rendered. On paraffin sections, the tumor was composed of spindle cells in fascicles traversed by thick ropy collagen fibers at places [Figure 1b-d]. Mitotic figures were occasional <1/50 high-power field and the tumor showed many thick-walled blood vessels. Foci of nuclear palisading were also noted and a differential diagnosis of schwannoma was considered. On IHC, the tumor cells expressed CD34 [Figure 2a], vimentin, and smooth muscle actin (SMA) [Figure 2b] and were negative for S100. In view of the immunoprofile and the histology, a final diagnosis of MFB was given. The patient is on follow-up and doing well.\nOUTPUT:" }, { "from": "agent", "value": "Myofibroblastoma of the Breast" } ]

[ { "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 37-year-old female patient, with typical symptoms of SIH and no history of trauma, was admitted to the hospital. Brain MRI showed peri hemispheric, subdural fluid collections, up to 4 mm thick [Figure 1]; reduced distance between the pons and the mammillary bodies to 4 mm, cerebellopontine angle reduced to 55 , and interpeduncular angle reduced to 51 . In addition, dilatation and rounding of the venous sinuses, rounding of the pituitary gland, absence of fluid in the optic nerve sheaths, and enhancement of the meninges were noted. MRI scan of the cervical, thoracic, and lumbar spine showed no abnormalities. Conservative treatment including bed rest and intravenous fluid infusions and corticosteroids were implemented. Isotope cisternography showed no evidence of a fluid fistula site. CT myelography with subdural administration of contrast mixed with saline in a ratio of 40/60 showed the fluid leakage site through the spinal nerve root sheath at the level of Th12/L1 intervertebral foramen on the right side [Figures 2 and 3]. Since CSF leakage was found on the level of intervertebral foramen, we decided to seal it with the patient's venous blood directly through the foramen instead of standard epidural puncture. For the procedure, the patient was placed on the CT table in the prone position. After confirmation of level Th12/L1 in the CT scout image, we, then, inserted 18G lumbar puncture needle to the intervertebral foramen Th12/L1 under the guidance of CT [Figure 4]. Having previously taken 10 ml of the patient's venous blood, we, then, injected it at the root exit site of the intervertebral foramen under CT guidance [Figure 5]. It is worth noticing that we, then, positioned the patient laterally, but on the opposite side to fistula for better spreading of the injected blood around the damaged nerve root sheath. The patient remained in this position in her own bed for another 2 h. Patient's verticalization started after the next 2 days. After the verticalization the patients, no longer complained about the headache during hospitalization and was discharged from hospital. During the follow-up visit, 1 month after hospitalization, the patient was completely free of headache and we found normalization of MRI image [Figure 6].\nOUTPUT:" }, { "from": "agent", "value": "Spontaneous Intracranial Hypotension" } ]

[ { "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 female patient was transferred from another hospital because of chest pain radiating to her back and thrombocytopenia. She had been diagnosed as having essential hypertension approximately 3 years earlier, but was not medicated. The chest pain developed upon exertion and radiated to her back the day prior to admission to a local hospital; it persisted and became more severe after admission. On admission, her temperature was 36.8 C, her pulse rate was 106, her respiration was 20, and her blood pressure was 190/100 mmHg. On physical examination, the patient appeared acutely ill, but her heart sounds were normal. A neurologic examination revealed no abnormalities. Laboratory test results are shown in Table 1. Urinalysis revealed many red blood cells and 0-5 white blood cells per high power field. Medical treatment started immediately with the infusion of nitroprusside and esmolol. On the 2nd day of admission, the patient reported an improvement in her chest pain, and she had a platelet count of 63,000/mm3. On the 7th day, her platelet count was 377,000/mm3, and her prothrombin and partial-thromboplastin times were normal. At 3 weeks after admission, her blood pressure and pulse rate had normalized and her chest pain had fully subsided. The DIC profiles, including platelet count, prothrombin and partial-thromboplastin times, D-dimer, FDP, antithrombin III, and fibrinogen, had normalized (Table 1). Outpatient follow-up by laboratory testing, thorax CT, and echocardiography have been performed at regular intervals over a period of 9 months, and the patient is doing well.\nOUTPUT:" }, { "from": "agent", "value": "Disseminated intravascular coagulation, Aortic dissecting aneurysm" } ]

[ { "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 73-year-old white male presented with a 2-year history of a pruritic, erythematous lesion over his scrotum. Physical examination revealed an erythematous plaque extending over the right and left scrotum with an uninvolved, 1.5 cm strip at the median raphe for a distance of 7 mm on either side. The involved area contained whitish superficial exudates but did not involve the base of the penis nor extend anywhere near the anoderm. The left side of the plaque extended 2 cm onto the left thigh; however, no involvement of the right thigh was noted (Figure 1). No inguinal lymph nodes were palpated on physical examination and the testes were descended bilaterally. His past medical history was significant for a right lower extremity deep venous thrombosis with pulmonary embolism one year prior to presentation for which he is taking Coumadin. He is also taking Albuterol and Symbicort for reactive airway disease. His past surgical history involved a vasectomy and epigastric hernia repair eleven years prior to presentation. His family history was negative for melanoma, colorectal cancer, or prostate cancer; however, his mother was diagnosed with breast cancer at age 60. The patient was advised to undergo a screening colonoscopy and diagnostic cystoscopy due to the associated complication of EMPD with colon cancer and cancer of the bladder. After both procedures revealed unremarkable results the patient underwent mapping biopsies and the specimens were sent to pathology for analysis. Histological examination showed fragments of skin with focal ulcerations and parakeratosis. There was no evidence of underlying malignancy noted; however, the dermis showed both mild acute and chronic focal inflammations.\nOUTPUT:" }, { "from": "agent", "value": "Extramammary Paget'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 a case study in a 16-year-old male with TS and comorbid OCB, rage attacks, sleeping problems, anxiety, and depression treatment with dronabinol (up to 33.6 mg/d) resulted in an improvement of both tics and psychiatric comorbidities including OCB. In a survey among adult patients with TS, 17 of 64 patients reported use of marijuana. Of these, 14 reported a reduction of tics and one a remission of OCB after use of cannabis. In a retrospective analysis efficacy and safety of smoked cannabis was investigated in 19 adults with TS. Of these, 15 patients were also diagnosed with comorbid OCD. In all of them, OCD improved according to Y-BOCS after starting treatment with cannabis. Only recently, results of a retrospective analysis (n=98) and an online survey (n=40) have been published in patients with TS, who had used different kinds of CBM including street cannabis, the cannabis extract nabiximols, dronabinol, and medicinal cannabis. In patients with comorbid OCD, improvement of OCD symptoms of 15% to 42% was reported. In a single-dose RCT (n=12) using 5.0, 7.5, or 10 mg THC, a significant improvement of OCB was found compared to placebo (mean reduction of 4.83 +- 5.59 according to the Tourette Syndrome Symptom List (TSSL), p=0.041). In contrast, in an RCT using up to 10 mg THC/d over 6 weeks in 24 patients no improvement of OCD was found. A summary of all studies in animal and humans is shown in Table 2.\nOUTPUT:" }, { "from": "agent", "value": "Obsessive-Compulsive 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 47-year-old female was found to have two masses in the right breast following a screening mammogram, as well as subsequent breast ultrasound and MRI. The E-cadherin immunostain demonstrated loss of membranous expression in the ALH, while stains for p63 and SMMHC demonstrated retained myoepithelial cells throughout the lesion. Following a discussion regarding treatment options, the patient underwent a right partial mastectomy and axillary sentinel lymph node biopsy, with adjuvant radiation of the right breast. Pathology from this surgery showed no residual tumor, and no tumor was identified in the two sentinel lymph nodes. Thyroid ultrasound prior to the thyroidectomy showed enlargement of both lobes, with heterogeneous echogenicity, and was suspicious for small calcification of the lower pole of the right lobe. This was followed by radioactive iodine therapy. About two and a half weeks later, she noticed edema, mild pain, and erythema of the right breast. However, we decided to evaluate the patient for possible inflammatory breast carcinoma, and incisional biopsies of the right breast were performed. Pathology revealed moderate chronic perivasculitis with edema of the dermis and no evidence of malignancy (Figures 1(a) and 1(b)). The patient was closely monitored, and her symptoms were noted to have improved on subsequent evaluation.\nOUTPUT:" }, { "from": "agent", "value": "Radiation Recall Dermatitis, Multifocal Papillary Thyroid Cancer, Ductal Carcinoma in Situ, Atypical Lobular Hyperplasia" } ]

[ { "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 presented a normal cognitive development. Body mass index at the time of first transition visit in the adult endocrinology department at the age of 18-years-old was 40.6 kg/m2 without glucose metabolism impairment. Lifestyle interventions failed because of poor compliance. During 20 months of 3.0 mg liraglutide treatment, a weight loss of 19 kg (-13.3%) and BMI reduction of 6.8 points were registered without side effects. The efficacy of liraglutide in BWS could be related to a crosstalk among glucagon-like peptide (GLP)-1 system, mechanisms related to the cyclin-dependent kinase inhibitor 1C (CDKN1C), and dopamine mesolimbic circuit. Image Caption and Description: \nImage caption: []\nImage description: []\nCase Report: \nAt the age of 16 years old, for recurrent otitis, he underwent surgical myringoplasty. Recurrent abdominal pain and episodical rectorrhagia were investigated, and the microscopic colitis lymphocytic colitis subtype was diagnosed.\nOUTPUT:" }, { "from": "agent", "value": "Beckwith-Wiedemann Syndrome, Syndromic Obesity" } ]

[ { "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: Analysis of the bacteria (Micro-ident, Hain Lifescience GmbH D-72147 Nehren) inside the pocket showed an infection with Peptostreptococcus micros and Fusobacterium nucleatum (orange complex) as well as Eikenella corrodens and Capnocytophaga sp. (green complex). The patient reported recurring inflammation in the left lower quadrant for a period of six weeks. Prior to the planned osteotomy of the wisdom tooth, the dentist had taken a scalpel biopsy, giving evidence for OSCC. Clinical examination revealed an ulcerous lesion with dominant signs of perifocal inflammation. The ulcer was delineated by a rigid wall of mucosa attached to the alveolar crest related to 37 and 38 (Figure 4). The patient declared to be a nonsmoker but admitted occasional alcohol consumption. Oral hygiene was assessed to be average, and no other precursor lesions were present. The patient underwent radical intended resection of the tumor. Figure 6 shows the resection specimen from a distal view. The tumor is mainly localized in the interdental space of 37 and 36 with distinct relation to the periodontal space of the crown 36. The beginning infiltration of the mouth floor becomes apparent. Figure 7 shows the microscopic view with arrosion of the bone by the tumor cells. HPV status by p16 immunostaining was negative.\nOUTPUT:" }, { "from": "agent", "value": "Squamous cell carcinoma of the left mandible, Chronic Periodontitis" } ]

[ { "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 1 is a natal female identifying as male (uses he/him/his pronouns) who was diagnosed with POTS in November 2014 at age 16 years. He had a 1 year history of dizziness and headaches, with subsequent onset of fatigue, cognitive dysfunction, insomnia (both in getting and staying asleep), early satiety, numbness, joint pain, heat and cold intolerance, exercise intolerance, dyspnea with activity, diaphoresis, palpitations, tachycardia, photophobia, and hyperacusis, and with the clinical findings of venous pooling, joint hypermobility, easy bruising, dislocation, and hyperelastic skin. At diagnosis, his medications included cyclobenzaprine, ibuprofen, and naproxen; he had allergies to latex, cetirizine, kiwi, and nuts. On examination, resting blood pressure was 122/80 mmHg. On 10-min stand, heart rate persistently went from 95 to 135 beats per minute. He was noted to have joint hypermobility and venous pooling, but an otherwise normal examination and ECG. He was treated with cyproheptadine for headache prophylaxis, fludrocortisone for dizziness, and pregabalin for pain:his three worst symptoms. The headaches resolved, but his dizziness persisted, despite attempts at therapy with fludrocortisone, midodrine, and desmopressin. His pain did not respond to pregabalin or duloxetine. The pain was severe enough to prevent routine exercise to suppress POTS symptoms.\nOUTPUT:" }, { "from": "agent", "value": "Postural Orthostatic Tachycardia Syndrome, hypermobile Ehlers-Danlos syndrome, exercise-induced asthma" } ]

[ { "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 CoD as described in hospital registers were retrospectively coded using the ICD-10-CM codes. Cause-specific mortality proportions were derived as the fraction of total deaths possibly associated to specific conditions, using hospital-based ICD-10-CM list diagnoses. Chest X-ray-Community Acquired Pneumonia compatible with endpoint consolidation\nRadiologically confirmed pneumonia i.e. Tuberculosis (TB), HIV or malaria and others. E): Deaths due to injuries \nThis consisted of under-five deaths with non-biological causes such as those resulting from injuries or accidents.\nOUTPUT:" }, { "from": "agent", "value": "Pneumococcal diseases" } ]

[ { "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: Her left breast appeared swollen, red and oedematous. Bilateral mammography showed a 3 cm mass in the left breast with increased skin thickness. Mammogram was normal in the right breast. Staging CT scan showed no sign of systemic disease and she started neoadjuvant therapy with Epirubicin plus Cyclophosphamide according to a dose-dense schedule (every 2 weeks). After four cycles she complained of pain in her right hip. 3A). She underwent radiotherapy to the proximal part of her right femur and subsequently initiates first line therapy with Trastuzumab, Pertuzumab and Docetaxel. Consistently, the MRI performed after 6 cycles demonstrated a dramatic reduction in number and size of bone metastases (Fig. 3B). After 9 months of treatment (12 cycles) she noticed reddening of her trunk and a swollen, oedematous right breast, the contralateral one, resembling a cutaneous infection. Topical steroids, oral nonsteroidal anti-inflammatory drugs (NSAIDs) and antibiotics were prescribed without any benefit. New small nodules appeared in the skin of the trunk and the pre-existing ones increased in size (Fig. 4). Nevertheless, disease remained in partial response in the bone and with no other site of metastatic spread as revealed by MRI (Fig. 3C) and CT scan, respectively. She discontinued treatment and started a second line therapy with TDM-1.\nOUTPUT:" }, { "from": "agent", "value": "Inflammatory breast cancer, Lymphangitis carcinomatosis, HER2-overexpressing, HR-negative IDC, Multiple metastases in the spine and pelvis, Neoplastic lesions in all vertebra and pelvic bones" } ]

[ { "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 30-year-old male presented with the acute onset of severe low back pain and bilateral lower extremity radiculopathy. Four orthopedic surgeons had recommended a lumbar discectomy. An IPMS treated him with two epidural steroid injections. The IPMS then stated he was a spine surgeon and then performed a percutaneous microdiscectomy in an outpatient surgical center. Notably, such outpatient centers typically have relaxed standards for vetting/credentialing spinal surgeons, and lower threshold requirements/indications for spine operations performed on their premises. Notably, postoperatively, the patient was told by the IPMS that; \"A large portion of the disc had been removed endoscopically, the nerve was freed up, and steroids/morphine were both applied to the surgical field.\" After consulting a spinal neurosurgeon, he underwent a bilateral L4-L5 laminoforaminotomy/microdiscectomy. Notably, at surgery, they encountered no scarring from the prior IPMS operation, confirming that the first was a \"sham\" operation. Following the bilateral L4-L5 laminoforaminotomy/microdiscectomy, the patient recovered.\nOUTPUT:" }, { "from": "agent", "value": "Large L4-L5 extruded disc herniation, Cauda equina 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 previously healthy 19-year-old man presented to the Urological emergency services with history of an erect penis of over 24 hours duration (Fig. 1). His penis was erect, painful and swollen when he arrived at emergency department. There was no history of trauma, malaise, night sweats, joint pain, and cough. The patient gave history of two similar previous episodes lasting for few hours and subsiding on its own in the past 1 month. The physical examination revealed that the liver was palpable 1-2 cm below the right costal margin, and spleen was 3 cm below the left costal margin. The conjunctiva appeared pale with no jaundice. The penis was erect, firm and tender with superficial venous engorgement. Laboratory data showed hemoglobin (Hb) 9.2 g/dl, hematocrit 25.7%, white blood count (WBC), 296,800/mm3, and platelet 936,000/mm3. Serum chemistries were unremarkable. The erection gradually reduced following aspirations and washes. 2). The Philadelphia chromosome was illustrated in the patient. He was started on hydroxyurea tablets at 1.5 g per day and Imitinib 40 gm per day. Allopurinol 300 mg daily with adequate hydration was also started for potential tumor lysis syndrome.\nOUTPUT:" }, { "from": "agent", "value": "Chronic Myeloid Leukemia, Priapism" } ]

[ { "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 male chronic smoker presented to the emergency department with complaints of retrosternal chest pain associated with perspiration of 3-h duration. He had two episodes of presyncope before reaching the hospital. At the time of presentation, his pulse rate was 48/min and systolic blood pressure was 90 mmHg. 12-lead ECG was obtained [Figure 1] that showed upsloping ST depression at J point in II, III, and aVF with positive T wave along with minimal ST elevation in aVR. Other leads showed horizontal or downsloping ST depression. On echocardiography, LV function was found to be normal with no regional wall motion abnormality at rest. Blood pressure responded adequately with intravenous fluids alone. Dual antiplatelets, unfractionated heparin, and nitrates were started. However, the patient and his relatives were not willing for coronary angiography at that time, and hence conservative management was continued. Troponin I was significantly raised. The patient became pain free over the next 2-3 h of medical management. He had recurrence of angina the next morning and after counseling again, he gave consent for revascularization. Coronary angioplasty was done with sirolimus-eluting stent (3 mm x 20 mm) [Figure 2]. There was complete pain resolution after angioplasty with normalization of ST segment in all leads [Figure 3]. He was discharged on the 3rd postoperative day without any complication.\nOUTPUT:" }, { "from": "agent", "value": "De Winter Sign in Inferior Leads, significant coronary artery disease, 99% thrombotic occlusion in the mid right coronary 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 17 year-old African American male with no significant past medical history presented to a physician's office for an influenza vaccination. He reported progressively worsening muffled voice, rhinorrhea, dysphagia, odynophagia, inability to breathe through nose and unintentional weight loss of 20 pounds in the preceding 2 months. He was immediately sent to the otolaryngology clinic for further evaluation. 1. 2. Immediately after extubation, he developed oxygen desaturation. His oxygenation did not improve with bag mask ventilation with 100% of oxygen, but improved only after a dose of succinylcholine. He was re-intubated and pink frothy fluid was suctioned from the endotracheal tube. 3. He received 40 mg of furosemide intravenously, which was repeated twice in the pediatric intensive care unit (PICU).\nOUTPUT:" }, { "from": "agent", "value": "Postobstructive pulmonary edema, Nasopharyngeal mass" } ]

[ { "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 77-year-old Japanese man visited our outpatient clinic with a slight pain on the neck. In addition, after the surgical treatment, he had received adjuvant chemotherapy (dacarbazine with interferon-beta, 3.0 x 106 U) for a half year. We screened for possible metastatic lesions with positron emission tomography and found an 11 mm nodule at the second cervical vertebra (Fig. 1a). Since the primary tumor was negative for the BRAFV600E mutation, we administered nivolumab at 2 mg/kg q3 weeks. Since a follow-up computed tomography scan 9 weeks after the administration of nivolumab revealed progression of the nodule at the second cervical vertebra, we employed IMRT (45 Gy in 5 fractions) 10 weeks after the administration of nivolumab. Seven weeks after the IMRT irradiation, the patient developed large, tense bullae and erosion arising on erythematous plaque on the trunk and extremities (Fig. 1b). A biopsy specimen revealed prominent interface dermatitis and dense infiltration of eosinophils in the upper dermis (Fig. 1c). Direct immunofluorescent study revealed IgG deposition on the epidermal side of the basement membrane zone. High levels of serum anti-BP180 NC16a antibody (73.1 U/mL) were detected. We treated him with oral prednisolone 20 mg/day with doxycycline (100 mg/day) with nivolumab. Two weeks later, the initial eruptions had disappeared and his disease was under control.\nOUTPUT:" }, { "from": "agent", "value": "Bullous Pemphigoid, Advanced 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: A 79-year-old Caucasian male presented to his primary care physician for routine follow-up in November 2020. He has a past medical history of insulin-dependent diabetes mellitus, essential hypertension, hyperlipidemia, and coronary artery disease with coronary artery bypass grafting and pacemaker placement. He denied any previous history of tobacco use. On physical examination, a nontender mass on the left side of his neck was easily palpable. Complete review of systems was otherwise negative except for increased forgetfulness. CT scan of the neck revealed a large mass arising from or immediately adjacent to the left parotid gland. Multiple left lung masses representing metastatic disease were also present on this scan. PET scan revealed 2.9 x 3.4 cm hypermetabolic soft tissue mass in the left parotid gland and extensive metastatic disease in the lung, mediastinum, liver, and bones. He underwent an ultrasound-guided biopsy of the left parotid mass and a CT-guided biopsy of a left lung nodule. Immunohistochemistry was positive for cytokeratin 7, GATA-3, and mammaglobin. HER2/neu and androgen receptors were positive in the lung biopsy. Magnetic resonance imaging (MRI) of the brain contained numerous ring-enhancing lesions, approximately 40-50. He received whole-brain radiation 30 cGy in 10 fractions in December 2020. He tolerated radiation therapy without complication. Following a discussion about goals of care, the patient decided against palliative chemotherapy. He did agree to androgen deprivation therapy with leuprolide. Next-generation sequencing identified no actionable targets except for HER2/neu amplification. He started lapatinib in February 2021. Despite dual therapy with leuprolide and lapatinib, he developed new visual symptoms prompting a repeat MRI of the brain on May 20, 2021, which revealed a mixed response to therapy. The majority of the central nervous system enhancing metastatic lesions decreased in size or resolved compared to the previous MRI on December 8, 2020. However, several new lesions were slightly more prominent than the previous ones. The patient decided to transition to comfort care and has been under home hospice since May 2020.\nOUTPUT:" }, { "from": "agent", "value": "Salivary Duct 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: Workup at the outside facility showed progression of disease with new pleural and hepatic metastasis. She was treated empirically for sepsis with antimicrobials and antifungals due to suspected infected MediPort, which was removed. Microbiological workup was unremarkable. She was transferred to our facility due to ongoing circulatory shock of unknown etiology. She was diagnosed with DI given her urine osmolarity of 202 mOsm/kg, urine specific gravity of 1.005, and urine sodium of 47 mOsm/kg in conjunction with a serum osmolarity of 298 mOsm/kg. Based on nephrology recommendations, she was continually treated with desmopressin, hydrochlorothiazide (HCTZ), and triamterene for mixed central and nephrogenic DI process. Despite her urine output decreasing, her stool output remained high, averaging 2700 mL per day. Clostridium difficile toxin and stool cultures were negative. New pleural and liver metastasis were visible on a repeat CT abdomen and pelvis as part of the workup with no other abnormalities seen in the GI tract (Figures 1(a) and 1(b)). In addition, our gastroenterology colleagues deemed her too unstable for any endoscopic evaluation including colonoscopy. A complete serological workup revealed only significantly elevated levels of chromogranin A and calcitonin (Table 1). Her overall conditioned continued to deteriorate and she developed multiorgan failure, refractory pain symptoms, and continued high stool output. Given her overall illness, she was deemed not a candidate for treatment of malignancy and opted for hospice care.\nOUTPUT:" }, { "from": "agent", "value": "Adenocarcinoma of the Lung, Paraneoplastic Diarrhea, Diabetes Insipidus" } ]

[ { "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 14-month-old boy (height 78 cm, weight 8 kg) with a history of Down syndrome, corrected tetralogy of Fallot, generalized epilepsy, and failure to thrive was accidentally diagnosed with a 4 mm sized cyst in the spleen during further investigation because of unsuccessful treatment of pneumonia. To verify the diagnosis in a few days the tests were repeated and E. granulosus IgG was found to be negative while Western blot confirmed positive IgG against E. multilocularis. The diagnosis of AE was confirmed and treatment with albendazole (ABZ) powder 10 mg/kg/day divided in two doses was prescribed. The patient was followed up every three months repeating abdominal ultrasound (US) and testing hepatic enzymes. During the course of the patient's follow-up no changes were seen: the size of the cyst remained the same (4 x 2.5 mm-3.9 x 2.7 mm), hepatic enzymes always remained within a normal range, and E. multilocularis IgG persisted to be positive:1.072 (OD) (cut-off 0.473). The patient was discussed with surgeons and it was decided that no intervention was indicated because of the small size of the cyst; thus the follow-up of the patient was continued. After 1 year, the treatment with ABZ was temporarily suspended because the patient underwent heart surgery for the tetralogy of Fallot. At that time in the place of cyst only hyperechogenic zone was found. However, three months later a 4 mm sized cyst in the same place with clear fluid and narrow borders was found again and treatment with ABZ 10 mg/kg/day was reinitiated. On the last examination (after 1 year and 8 months of treatment) no positive changes were seen: E. multilocularis IgG remained high (1.75 (OD), cut-off 0.99) and the cyst was of the same size; however, no new foci were detected. The boy tolerates the medication well and is continued to be followed up every three months.\nOUTPUT:" }, { "from": "agent", "value": "Alveolar Echinococcosis" } ]

[ { "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). 2) (See Additional file 2: ICE1.mpeg for the unusual intracardiac anatomy). Several unsuccessful attempts were made to change its direction towards the oval fossa. That was also deemed a condition predisposing to complicated transseptal puncture (Fig. 3) (See Additional file 3: ICE2.mpeg for the sliding of the transseptal needle towards the aorta). During the procedure two echocardiographers, including the one, which had performed the TEE, re-evaluated the videotaped TEE and agreement was achieved that the initial interpretation of the TEE needed correction. Only a cavotricuspid isthmus ablation was done.\nOUTPUT:" }, { "from": "agent", "value": "Paroxysmal atrial fibrillation, Atrial flutter, Arterial hypertension, Aneurysm of the IAS, Dilated aortic root, Enlarged right atrium" } ]

[ { "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 56 year-old female presented to department of Bariatric surgery complaining of sever obesity and articular pain in lower limbs, her weight was 110 kg, Height 167 cm and Body Mass Index (BMI) was 39.44 kg/m2. As a history she has Diabetes Mellitus (DM) that complicated prior with a left hemi foot amputation. As she is a diabetic patient, she was on Insulin after failure of oral hypoglycemic medications. The patient had previously conservative treatment for obesity with Orlistat, which had no effective impact on her weight. Her TSH and Serum Cortisol values were normal. Therefore, the patient was advised to operate surgery because of her high BMI and failure of obesity conservative treatment. Through surgery preparation, her lab tests were normal, upper gastrointestinal endoscopy UGI and abdominal ultrasound both had revealed no abnormal findings. We operated the patient by abdominal laparoscopy with sleeve gastrectomy, at the beginning of procedure, we discovered an incidental rounded, less than 2 cm small mass on the anterior aspect of the stomach (Fig. 1), it was not compromising the performance of a save vertical gastric resection, so the resection was done and a mass specimen was sent for pathological examination. Pathology report revealed 1.3 mm in diameter mass, comprised of spindle cells with minimal nuclear pleomorphism and a few mitotic activity (mitotic index 1-2 x 10 high power fields) (Fig. The tumor invaded the gastric wall, penetrated the submucousal layer and reached the mucous layer without infiltrating it. Through immunologic examination, all tumor cells reacted positively to CD117 with Dako EnVision system. After surgery, the patient is in a good condition, she lost 25 kg through 3 months, her fasting blood sugar is around normal (100-130 mg/dl), and the tumor required no additional treatment.\nOUTPUT:" }, { "from": "agent", "value": "Gastrointestinal Stromal Tumor (GIST)" } ]

[ { "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 received adjuvant chemotherapy one month after the operation. A combination of CDDP at 80 mg/m2 and vinorelbine at 25 mg/m2 was administered on the first day of adjuvant chemotherapy. Fig. On the third day, blood tests revealed grade 4 liver enzyme elevation (alanine aminotransferase [ALT] level: 1,179 IU/L), grade 2 bilirubin elevation (1.7 mg/dL), and grade 2 creatinine elevation (1.11 mg/dL). On the 5th day, the patient suffered from a grade 3 hearing impairment, leading to grade a 4 complete loss of hearing ability. On the 8th day, the acute kidney injury progressed to grade 4 (creatinine level: 3.62 mg/dL), and intermittent hemodialysis was performed. Myelosuppression was also observed, and recombinant human granulocyte colony-stimulating factor was administered to prevent febrile neutropenia. The nadir of the neutrophil and platelet counts was 1,630/muL (grade 1) on the 14th day and 19,000/muL (grade 4) on the 10th day, respectively. A systemic survey including CT of the brain, chest, and abdomen showed no recurrence of lung cancer. Irrespective of intensive treatment, multiple organ failure and systemic infection progressed, and the patient died on the 59th day after the initiation of chemotherapy.\nOUTPUT:" }, { "from": "agent", "value": "Cisplatin-induced Severe Adverse Events, Xeroderma Pigmentosum" } ]

[ { "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 13-year-old female child presented with the complaints of pain associated with swelling in the left popliteal region for 6 months, which gradually increased in size. There was no history of major trauma and no significant family history. MRI of the left knee joint was done, which showed a lobulated mass in the posterior aspect of the left knee joint extending into the calf [Figure 1]. It was an R0 resection with margins free of tumor. She recovered well and was asymptomatic for 6 months, after which she presented with pain in the surgical bed while walking. MRI of the left knee was done, which showed a soft-tissue mass in the popliteal fossa with intra-articular extension and encasing neurovascular bundles and was suggestive of disease recurrence [Figure 2]. She was referred for 18F-fluorodeoxyglucose (FDG) PET/CT scan to rule out multifocality of the disease. 18F-FDG PET/CT of the whole body from the skull till the toes was done in the Outpatient Department of Nuclear Medicine, Apollo Hospitals, 60 min postinjection of 5 mCi of 18F-FDG. 18F-FDG PET/CT scan showed a low-grade FDG-avid mass measuring 13 cm (craniocaudal) x 6.1 cm (transverse) x 4.4 cms (anteroposterior) in the left popliteal fossa involving the gastrocnemius (medial head and proximal part of the lateral head) and popliteus muscles with minimal intra-articular extension and encasing popliteal vessels with maximum standardized uptake value (SUVmax) of 2.9. No evidence of bone erosion was noted. No other focus of metabolically active disease was seen elsewhere [Figures 3-4]. As the recurrent mass was inoperable, the patient was advised for systemic chemotherapy with vinblastine and methotrexate.\nOUTPUT:" }, { "from": "agent", "value": "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: A 44-year-old woman (body mass index, 24.1 kg/m2) with alcohol-associated osteonecrosis of the right femoral head (stage 4, Association Research Circulation Osseous staging system) underwent THA with the use of a TPP at our hospital (Fig. 1, Fig. 2). She had a history of alcohol consumption, but otherwise was healthy. The thrust plate was inserted at a femoral shaft-neck angle of 130 on an anteroposterior radiograph, which is reportedly the optimal insertion angle (Fig. 2a). The thrust plate was placed in full contact with the medial cortical bone of the femoral head. The patient reported that her preoperative hip pain had resolved. Neither cup nor stem loosening was observed at annual clinical examinations. Thirteen years after the THA, the patient slipped and fell to the floor and suffered a low energy trauma. She returned to our hospital where a plain radiograph showed a displaced subtrochanteric fracture of the right femur below the distal tip of the lateral plate without implant loosening (Fig. 3), which was classified as a type B1 fracture according to Vancouver categories. The patient underwent revision combined with ORIF. Intraoperatively, it was difficult to remove the TPP because of marked bone growth on the surface of the thrust plate. Thorough drilling around the thrust plate using a Kirschner wire was required to minimize the loss of cancellous bone at the proximal femur. Sufficient stability of the fracture sites was observed with the use of a long distally fixed intramedullary stem (K-MAX S-LOCK system; Japan Medical Materials, Osaka, Japan) in conjunction with a plate and cable system (Cable-Ready Greater Trochanteric Reattachment Plate; Zimmer, Warsaw, IN, USA) (Fig. 4). Partial weight-bearing walking was permitted 4 weeks after surgery, and full weight-bearing walking was initiated 2 months later. Bone union was radiographically confirmed 3 months after surgery. At her 18-month follow-up, the patient was mostly asymptomatic and her Harris hip score was 92 points.\nOUTPUT:" }, { "from": "agent", "value": "Periprosthetic femoral fracture" } ]

[ { "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 what follows, I present and interpret three case studies of patients who experienced behavioral changes after DBS treatment. These case studies stem from an article by Schupbach et al. in the journal Neurology. In that article, Schupbach et al. report their findings from a study conducted by psychologists, neurologists, and a psychiatrist between 2000 and 2003 of 29 Parkinson patients (15 male, 14 female) treated with DBS. The interview technique is described as '[r]epeated open, unstructured interviews conducted by trained psychologists [...], neurologists [...], and a psychiatrist [...]' in order to 'qualitatively assess the impact of STN stimulation on the patients' personal, marital, and socio-professional life. '(: 1811f. ).13 The original aim of the study was to 'prospectively examine 'kinds of 'social maladjustment experienced by 29 patients with PD before and 18 to 24 months after bilateral STN stimulation' (: 1811, my italics, FK).14 \nHowever, I argue that the emphasis on the notions 'social adaptation' and 'maladaptation' or 'maladjustment' fails to capture an important dimension of the patients' experience, namely, the subjective experience of authenticity and alienation. Accordingly, I offer a different interpretation of these cases, relying on the heuristic tools of authenticity and alienation, which aims at showing that the application of these concepts makes the content of the case studies more accessible to philosophers and ethicists, and, moreover, reveals that what the psychologists interpreted as 'maladaption' can, in fact, be interpreted in a different and positive philosophical light. This suggests that maybe we need to construct new tools for evaluating patients' behavior in the future, which reflect not only the third-personal 'adaption' criteria, but also the first-personal self-ascriptions of authenticity and alienation. We are now in the position to look at some case-studies.\nOUTPUT:" }, { "from": "agent", "value": "Deep Brain Stimulation behavioral changes" } ]

[ { "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 boy with eczema presented with high fever (40 C), tachycardia (heart rate 200 per minute), oliguria, and respiratory failure. He was treated with cefotaxime for presumed septic shock. Echocardiography showed mildly impaired left ventricular function. He was also noted to have hemoglobin 7.7 g/dL, absolute neutrophil 0.37 x 109/L, and platelet 117,000/mm3. An urgent bone marrow examination revealed pure red-cell aplasia with granulocytic maturation arrest and reactive changes but no malignant infiltration. The patient was stabilized with mechanical ventilation, red-cell transfusion, antibiotics, and low-dose adrenaline infusion. He was also noted to have an ulcerated lesion over his left forearm. The family had two cats, and they lived in a village house. Bed bugs were also found to be present in old furniture. The child's condition gradually improved after 4 days of treatment. He was able to be extubated and weaned off inotropic support. Haemoglobin, neutrophil, and platelet counts normalized over a week.\nOUTPUT:" }, { "from": "agent", "value": "Staphylococcus aureus Infections, Transient Erythroblastopenia of Childhood (TEC), Hemophagocytic Lymphohistiocytosis (HLH)" } ]

[ { "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 now Para 1 was referred from a peripheral hospital to the Teaching Hospital because of persistent \"bearing down\" efforts after a spontaneous vaginal delivery of a live male neonate with birth weight of 3400 gm six (6) hours prior to presentation. The labour had lasted about 9 hours. The birth attendant, having examined the patient again and excluded the possibility of an undiagnosed twin, decided to refer her for expert management. Examination on admission revealed a young lady who was pale, dehydrated, and intermittently straining in response to \"the irresistible urge to push.\" Her pulse rate was 102 beats/min, regular and of moderate volume with a blood pressure of 120/70 mmHg. The uterus was about 20-week pregnancy size and was well contracted. Pelvic examination revealed a blood-smeared vulva with a tender swelling involving the right labia minus and majus measuring about 4 cm by 4 cm. The plan was to institute conservative management with vaginal pack and analgesics. Intravenous access was established and blood sample was obtained for packed cell volume (PCV) (which was 22%) and grouping and cross-matching of three units of whole blood. The limits of the swelling were ink-marked and observed for one hour to confirm if there would be an enlargement. Progressive expansion of the VVH occurred, necessitating surgical intervention. The intraoperative findings included a huge 12 cm by 10 cm right vulvovaginal haematoma completely occluding the vaginal cavity and stretching the overlying perineal skin (Figures 1 and 2). There was no significant bleeding from the vagina. Incision and evacuation of the haematoma and exploration of the cavity were done and 1500 mls of clotted blood was evacuated from the cavity. Haemostasis was achieved with \"figure-of-eight\" sutures. The space was obliterated with deep sutures and the overlying skin approximated carefully, avoiding injury to the urethra. The vagina was packed with gauze to further assist with haemostasis (Figure 3). She had broad-spectrum antibiotics and transfusion of three units of blood and was discharged home on the third day following a satisfactory postoperative recovery.\nOUTPUT:" }, { "from": "agent", "value": "Puerperal genital haematoma" } ]

[ { "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 42-year-old male was brought to our emergency room with an episode of loss of consciousness for half hour. The patient had been complaining of headache, blurring of vision in the left eye and vomiting for the past 1 month. He was drowsy, confused and irritable. His general physical examination was normal. He had relative afferent pupillary defect in the left eye. Optic fundus examination showed bilateral papilloedema. Visual assessment performed subsequently showed no perception of light in the left eye and a visual acuity of 6/24 in the right eye. CT scan showed a large heterogeneous ill-defined lesion in the suprasellar region, which extended into the left basifrontal region and through the left optic canal into the left orbit. The optic nerve sheath complex appeared thickened and tortuous, and showed peripheral tram-track-like calcification with a widened optic canal. Minimal hydrocephalus was seen (Figure 1). MRI of the brain showed a large heterogeneous ill-defined lesion seen in the suprasellar region, which extended superiorly into the left basifrontal region and anteriorly through the left optic canal into the left orbit. The left optic nerve appeared thickened and showed tram-track calcification. The optic tract and the chiasma were not seen separately from the lesion. The lesion was seen exerting significant mass effect on the anterior aspect of the left lateral ventricle and the floor of the third ventricle, causing obstructive hydrocephalus and cerebral oedema. Posteriorly, the lesion was seen extending into the interpeduncular cistern (Figures 2 and 3). The patient suffered a seizure during the MRI; hence, contrast-enhanced MRI could not be performed. Diagnoses of optic pathway glioma and meningioma were considered. The patient was taken up for emergency surgery. Left frontal craniotomy with decompression of the tumour was performed and sample was sent for histopathology. The tumour was very vascular and had variable consistency with areas of gritty calcification. Areas of necrosis filled with dark brown-coloured fluid were seen. A ventriculoperitoneal shunt tube was placed for relieving the hydrocephalus. He was then treated with intensity-modulated radiotherapy and chemotherapy with temozolomide.\nOUTPUT:" }, { "from": "agent", "value": "Anaplastic oligoastrocytoma" } ]

[ { "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 spontaneously stopped his clopidogrel treatment (aortic-bifemoral bypass 15 years earlier) twelve days earlier. He was treated by repeated left anterior packings that were effective but bleeding recurrences were immediate after each packing removal. A bilateral sphenopalatine artery cautery was performed under general anesthesia on February 29. After postoperative packing removal, the patient bled. The patient was transferred to the ENT unit of Croix-Rousse Hospital on March 14. After anterior packing removal, his left nasal cavity was filled with Surgiflo without local anesthesia. The patient was able to leave the hospital after two days of monitoring without bleeding. No local cause was found when the patient was seen in ENT consultation on March 27, without bleeding recurrence. The patient only complained about a nasal obstruction 15 days after Surgiflo was applied.\nOUTPUT:" }, { "from": "agent", "value": "Recurrent Epistaxis, Thrombocytopenia, Primitive Myelofibrosis" } ]

[ { "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 arthralgia and back pain lasting for several months and recent metatarsophalangeal luxation of the left toe presented to the ambulatory unit of rehabilitation clinics. The patient had joint hypermobility since childhood, diagnosed as ligament laxity. In adolescence, she is remembered to be called \"a clumsy freak\" due to joint mobility. At physical evaluation, marfanoid habitus with waxy, sagging skin and varicose veins in the feet was observed. Sclerae were bluish and eyelids dropping. In fingers and toes, spontaneous subluxation in all joints could be elicited. Elbows, knees, and all fingers were overextended. She had flat feet with a bilateral hallux valgus (Figure 1). She had scoliosis with prominent kyphosis. Lungs auscultation was characteristic of chronic obstructive pulmonary disease (COPD); the murmur of mitral valve prolapse was heard over the chest. On the Beighton score, she received all (9) scores: passive apposition of the thumb to forearm and passive dorsal hyperextension of the metacarpophalangeal joint >90 on both sides were done with no strain (Figure 2); she was able to actively hyperextend both elbows and knees on both sides over >10 and flex her spine to the ground with palms placed on the ground without knee flexing. On Five-point Hypermobility Questionnaire, she answered \"yes\" to all questions. She remembered vividly contorting her body into strange shapes and being called names by other children. In the ambulatory unit, she received systematic, light, nonweightbearing, and proprioception exercises; she was referred to the occupational therapist for lower limb orthosis; she was taught relaxation techniques including mindfulness-based stress reduction and counselling support, though she was already familiar with cognitive behavioural therapy. She used regular anti-inflammatory drugs. She was referred to the plastic surgeon due to the wound on her foot, since sutures should be applied generously, without tension, in layers, and left in place twice as long as usual. She was already regularly followed by her cardiologist due to mitral valve prolapse.\nOUTPUT:" }, { "from": "agent", "value": "Ehlers-Danlos 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 77-year-old man without a particular family history but with a past medical history of peripheral arterial occlusive disease that was surgically treated including long-term oral anticoagulation with coumarin presented with sudden onset chest discomfort at rest. He was admitted to our hospital. Hemodynamics were stable. There were no rales or heart murmurs, except S4 of the heart sound. Electrocardiography showed sinus rhythm with non-specific ST-segment changes in leads I, II, aVL, aVF and V3-6. Arterial blood pressure was 130/100 mmHg on the right arm and 110/60 mmHg on the left. The chest pain initiated with a blow and then migrated toward the lumbar area over time. The patient was oliguric 8 hours after admission. No other symptoms suggesting cerebral, spinal or peripheral perfusion deficits or hematoma formation were present. Laboratory examination identified elevated D-dimer levels and an INR of 3.44; other blood tests including cardiac markers and renal function tests were normal. PCC at a dose of 45 IU per kg body weight were administered i.v. in combination with 10 mg of vitamin K1. He was then transferred to Verona University Hospital approximately 10 h after the onset. Two and a half hours after intravenous administration of PCC the INR was 1.6. Emergency graft replacement of the ascending aorta was performed. Surgical therapy was performed without complication and the postoperative clinical course was uneventful. Renal other organ functions remained normal and unaffected, respectively. The patient was transferred to his home hospital in Germany on the 6th postoperative day in stable condition after oral anticoagulation with coumarin was again begun.\nOUTPUT:" }, { "from": "agent", "value": "Stanford type A 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: We present the case of a 43-year-old female. Shortly after birth, she presented a spontaneous right hip fracture. From then, until now, she has had multiple fractures of both arms and legs, which have required several interventions for correction, needing on the left humerus to be fixed with a medullary locking (Figure 1). The last fracture episode happened 3 years ago. OI type 2 was diagnosed, 20 years ago. For moving at home, she walks with difficulty with a cane, and, on the street, she is moved by wheelchair. She presents a significant growth delay (High = 1'14 m) and weighed 65 kg, presenting a picture of morbid obesity, with an increased body mass index (BMI = 45.4 kg/m2). She relates that for about 2 years, and she has slow digestion, accompanied by marked abdominal bloating, accompanied by heartburn and reflux. The major alteration in her bowel habit was an alternating pattern with diarrhea and constipation. The patient had also bilateral hearing loss, requiring hearing aids for ten years. Currently, the CBC was normal. Blood glucose was elevated (230 mg/dL) with increased glucosuria (4+). The rest of biochemical analysis was normal. She underwent a gastroscopy that showed a moderate reflux oesophagitis (grade B Angeles classification) without associated hiatal hernia. Duodenal biopsies showed an increased intraepithelial lymphocytosis (45%) corresponding to stage I of affordable Marsh. Genetic markers of CD type DQ2 were positive in homozygosis, and antibodies to tissue transglutaminase (tTG) were normal (0.6 U/mL). Antinuclear antibodies were negative. Vitamin D deficiency was excluded. A recently completed study of bone mineral density (BMD) has been reported as normal.\nOUTPUT:" }, { "from": "agent", "value": "Osteogenesis Imperfecta, Celiac Disease, Type II 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: The methadone dose was incrementally increased throughout the pregnancy to 105 mg daily and ultimately 165 mg daily through delivery. There were no reported adverse drug interactions and electrocardiogram (ECG) monitoring did not reveal QT prolongation. A combined spinal-epidural (CSE) block procedure was performed at L4/5. Spinal medications included 0.5% bupivacaine 1.8 mL, morphine 200 mcg, fentanyl 10mcg, and epinephrine 200mcg. The epidural was dosed incrementally with 2% lidocaine with 1:200,000 epinephrine 13 mL to maintain patient comfort during the surgical procedure. The operative course was uncomplicated. The epidural catheter was left in place after surgery and a continuous epidural infusion of 0.0625% bupivacaine with fentanyl 4 mcg/mL was initiated at 10 mL/hr (patient-controlled dose 4 mL, 15-mins lockout) and continued until approximately 18 hrs post-operatively. The patient reported generally effective pain relief during this time, though she was not able to ambulate due to partial motor block from the epidural local anesthetic infusion. Her other postoperative management included scheduled oral methadone 165 mg daily, IV ketorolac (given from 0 to 24 hrs), oral ibuprofen (given from 24 hrs until discharge). Oral oxycodone and oral acetaminophen were available as needed for breakthrough pain. Pain control was difficult after epidural catheter removal, reflected by average daily oral oxycodone 85 mg per 24 hrs (range 45-100 mg per 24 hrs) and average maximum daily pain scores of 8/10 (range 7-10/10) during her hospitalization after delivery. No significant events were observed on continuous pulse oximetry and telemetry monitoring during her hospitalization. Hospital discharge occurred 3 days 22 hrs after delivery (Table 1).\nOUTPUT:" }, { "from": "agent", "value": "Chronic hypertension with superimposed preeclampsia, Opioid use disorder, Morbid obesity" } ]

[ { "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 66-year-old Japanese woman was observed to have a paraesophageal mass during a health checkup, for which, she was admitted to the hospital in 2016. She had no family history of genetic diseases. As malignancy was suspected, tests were performed, which revealed normal levels of carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) at 0.8 ng/mL and 4.8 pg/mL, respectively. Chest computed tomography (CT) showed a localized area of low density, measuring approximately 2.8 x 2.5 x 2.3 cm3, on the right side of the esophagus in the lower part of the mediastinum (Fig. 1). 2). 3). Since we usually perform thoracoscopic esophagectomy for esophageal carcinoma with the patient in the prone position, the same method was adopted for this case. Four chest trocars were introduced (Fig. 4A). During the surgery, the lesion could be easily separated from the esophagus and was seen to be located on the crura of the diaphragm rather than on the esophagus (Fig. 4B and C). The surface of the mass was smooth and complete. Pathological examination revealed that the lesion contained fibrous and fatty wall-structures and was internally lined with typical pseudostratified ciliated columnar epithelium (Fig. 5). Postoperatively, the patient recovered uneventfully and was discharged from the hospital after 7 days. No recurrence was noted during the 2-year follow-up.\nOUTPUT:" }, { "from": "agent", "value": "Bronchogenic cyst" } ]

[ { "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: Our patient is a 53-year-old African American female with no significant past medical, surgical, or family history who presented to our facility with a three-month complaint of right flank pain that was localized, gradually worsening, and graded as 7/10 by her. She is P3003, married, and had undergone a Papaniclaou (PAP) smear with an uneventful outcome (according to her) three years prior to presentation. A computerized tomography (CT) scan of the abdomen showed an 11.7x10x8 cm right flank mass (Figure 1) consistent with a large exophytic mass highly suspicious for a renal cell neoplasm. A subsequent CT scan of the head, chest, abdomen, and pelvis was negative for any obvious metastases. Our patient was discharged on postoperative day 4 in a stable condition, and she opted for a herbal remedy rather than chemoradiation therapy. On postoperative day 30, our patient presented to the emergency room (ER) with persistent vaginal bleeding for 11 days; on physical examination, a bulky cervical mass of 7x8 cm with bilateral parametrial infiltration extending to the pelvic wall was seen and biopsied. A repeat CT scan of the chest, abdomen, and pelvis with contrast revealed no obvious metastases and a 7.9x6.8 cm heterogeneous soft tissue mass within the lower uterine segment (Figure 3), which a pelvic sonogram confirmed by showing a 6.4x6.9x7.7 cm cervical growth. She re-presented to the ER nine months later with marked anemia (hemoglobin: 5.1 mg/dL), generalized weakness, and poor functional status. A repeat CT scan and sonogram of the abdomen showed multiple metastases in the right flank with possible distant metastases in the liver. She also complained of severe back pain, and eventually passed away one week after re-admission.\nOUTPUT:" }, { "from": "agent", "value": "Leiomyosarcoma of the right kidney, Squamous cell carcinoma of the cervix" } ]

[ { "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 59-year-old man presented to the emergency room complaining of abdominal pain and distention for 2 months duration. He also complained of 35 lbs unintentional weight loss, loss of appetite, shortness of breath, dizziness, and generalized weakness. He otherwise denied fever, chills, and night sweats. Initial vital signs were stable and physical examination was only notable for a soft, distended abdomen with tenderness over the left upper quadrant. Complete blood count showed pancytopenia, with white blood cell count of 2.4/microL (4.4-11 x 103/microL), hemoglobin 8.2 g/dL (13.5-17.5 g/dL), and platelets 60/microL (150-400/microL). Initial complete metabolic panel showed bicarbonate 15 mmol/L (22-28 mmol/L), alkaline phosphatase 118 U/L (40-115 U/L), and lactic acid 10.1 mmol/L (0-2 mmol/L). Computed tomography abdomen pelvis with oral and IV (intravenous) contrast showed massive splenomegaly measuring about 26 x 17 x 9 cm, with a minimum volume of 2 L along with retroperitoneal and mediastinal lymph nodes. The patient then underwent a bone marrow biopsy, which showed a hypercellular bone marrow and florid population of B-cell lymphocytes positive for CD5, CD20, CD22, CD43, CD79a, cyclin D1, and BCL-2 with rare CD10 positive B-cell lymphocytes, and negative CD23 (Figure 1a-e). Scattered background T-cell lymphocytes were highlighted with CD3. Rare hematopoietic cells including dysmorphic megakaryocyte were noted. The patient was diagnosed with MCL. Throughout his stay in the hospital, he had persistently elevated type B lactic acidosis that was non-responsive to fluids. Only on starting therapy with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) as an outpatient did an improvement in lactic acidosis become evident. A computed tomography scan of the abdomen pelvis with IV contrast, midway through the R-CHOP cycles, showed massive splenomegaly with several unchanged prominent retroperitoneal lymph nodes, but an improvement in lactic acidosis was seen. The patient was subsequently referred for evaluation for hematopoietic stem cell transplant.\nOUTPUT:" }, { "from": "agent", "value": "Mantle Cell 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 45-year-old man with a history of myopia and had received cataract surgeries in both eyes at a local eye clinic 6 years ago without information of IOL material. He suffered from a sudden onset of floaters with progressive visual field defect in his left eye for 4 days before he visited our hospital. Under slit lamp examination, the 3-piece posterior chamber IOLs were in capsular bags in both eyes under status of post neodymium:YAG laser posterior capsulotomy. An encircling scleral buckle and a standard 20-gauge 3-port pars plana vitrectomy with silicone oil instillation was performed successfully. However, an oval-shaped silicone oil droplet was found on the posterior surface of the IOL in the visual axis with complaints of distorted micropsia and poor vision a month later (Figure 1). His vision then decreased to 3/20 in his left eye. The refraction could not be measured by automatic refractometry. Another pars plana vitrectomy of a 20-gauge system (Alcon Accurus 400VS surgical system) was performed. A 20-gauge infusion cannula was placed in the inferotemporal site, and a 20-gauge vitreous cutter was passed through the superonasal site. The largest silicone oil droplet was aspirated with a higher aspiration setting of 300 mmHg as the opening of vitrector was totally buried inside the silicone oil droplets. The residual smaller ones at the center of the visual axis were swept peripherally by a 27-gauge bending tip cannula (Figure 2). After the silicone oil was removed, the surface of the IOL was clear in the visual axis. The patient's visual acuity returned to 20/20 without distortion and micropsia.\nOUTPUT:" }, { "from": "agent", "value": "Retinal 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: About two months prior to this admission for depression, he had been involuntarily hospitalized at another facility for mania. Standard laboratory measures, which were within normal limits, and a urine toxicology screen, which was negative, were obtained prior to admission. During the initial days on our service, the patient endorsed depressed mood and low energy. He had profound hypersomnia and slept through the night and much of the day. He rarely would attend group therapy or socialize with staff or other patients. The patient was started on modafinil 100 mg daily with plans to use short term to help combat hypersomnia. Psychiatric medications at the time included divalproex 2,500 mg QHS, quetiapine 300 mg QHS, and venlafaxine 225 mg once daily. Venlafaxine had been increased to 225 mg several weeks prior to initiation of modafinil. His valproic acid level prior to initiation of modafinil was found to be 79 ug/ml, confirming adequate prophylactic treatment of mania. There were no other changes made to his medication regimen at this time. This included seeing trees moving in his bedroom, beliefs that there were cameras in the pictures on his wall, and that a water bottle was \"transmitting something\" into his room. The following day the patient demonstrated more psychotic behaviors including waking his roommate up in the middle of the night to accuse his roommate of abusing his daughter and later accusing the treatment team of including him in experimental research. Following these psychotic events, the modafinil was discontinued and the psychotic features subsided within the following days.\nOUTPUT:" }, { "from": "agent", "value": "Modafinil Induced Psychosis, Bipolar 1 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: She underwent a surgical debulking procedure at the age of 17, but the lesion continued to expand. Schooling and work were unaffected till the age of 21; however, due to pain, weakness, and coordination difficulties, she was not able to return to employment. On examination, an extensive vascular anomaly was noted to involve the palm, index and middle fingers, and distal forearm and wrist [Figure 1a], with bruit and a palpable thrill. The tips of the thumb and ring and little fingers were cool. To monitor the \"steal\" phenomenon affecting the thumb and ulnar-sided digits, a thermal image was recorded in the clinic using an FLIR SC660 thermal imaging camera (FLIR Systems Inc., Wilsonville, Oregon, USA). Images were recorded at 22 C and 50% relative humidity at a distance of 70 cm after exposure of the hand for 3 min to allow surface cooling of the skin. To date, the patient has declined any radiological or surgical intervention to date and is managed with a compression garment and simple analgesia for pain relief.\nOUTPUT:" }, { "from": "agent", "value": "Vascular Malformation of the Hand, Type-A AVM" } ]

[ { "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 40-year-old obese man with a history of hypertension, methamphetamine use, and heart failure presented to an outside ED with chest discomfort and shortness of breath. A chest x-ray revealed a right paratracheal mass measuring 6 cm which was confirmed on follow-up CT. CT also showed a small right-sided pleural effusion and moderate hilar, mediastinal, mesenteric and pelvic lymphadenopathy (Fig. 1). The initial outside radiographic read considered these imaging findings concerning for lymphoma vs. metastatic primary lung malignancy. The Hounsfield Units of the initial scan were 17.8. The patient was initially referred to thoracic surgery, but given the proximity of the lesion to the trachea, thoracic surgery referred the patient for consultation by interventional pulmonary with endobronchial ultrasound (EBUS) guided transbronchial needle aspiration (TBNA). Bronchoscopy with EBUS guided FNA was performed in the operating room under general anesthesia using a laryngeal mask airway (LMA). To our surprise, the mass was hypoechoic, yet Doppler US (Fig. 2a) did not suggest any blood flow through the lesion. A 22 gauge EBUS needle was inserted into the lesion under direct US guidance. On aspiration, the syringe filled with a serous fluid (Fig. 2b). Cytologic analysis of the sample showed a paucicellular proteinaceous fluid with occasional foamy macrophages and no evidence of malignancy. In addition, re-read of the outside CT suggested the presence of a PE, which helped explain the hilar and mediastinal adenopathy and pleural effusion. Due to concern for PE, a repeat PE protocol CT was performed showing no evidence of a current PE; furthermore, it showed resolution of the ipsilateral pleural effusion and hilar and mediastinal lymphadenopathy. 3). Since undergoing EBUS guided TBNA, our patient has reported a good functional outcome with total resolution of his symptoms and greatly improved exercise tolerance.\nOUTPUT:" }, { "from": "agent", "value": "Bronchogenic cyst" } ]

[ { "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-years-old Chinese woman was admitted to our department due to dry mouth and dry eyes on October 11th, 2019. She suffered from dry mouth for 1 year but without decay of teeth or swelling of parotid glands. Two months before her admission, she began to have dry eyes and asymmetrical fatiguable ptosis. She also developed diplopia, dizziness and proximal muscle fatigability of lower limbs. She was identified as an asymptomatic hepatitis B virus carrier for 8 years. On admission, physical examination showed bilateral ptosis, more serious on the right side. Bilateral limitation of eye movement. No oral saliva pool. Muscle strength of proximal muscles of lower limbs was grade IV. She was given a comprehensive laboratory examination involving blood cells, acute phase response markers, serum biochemistry, CK, immunoglobulins, autoantibodies, and hepatitis B virus markers. The clinically significant results showed as follows: hepatitis B surface antigen (HBsAg), hepatitis B e antibody (anti-HBe), and hepatitis B core antibody (anti-HBc) positive. The levels of CK was normal. RF was 76 IU/ml. The level of anti-TPO antibody was 78.6 IU/ml (0-9), anti-TG antibody 10.6 IU/ml (0-4), but thyroid function normal. The MAA and MSA were all negative. ANA was positive with a titer of 1:320 (homogeneous pattern). Ig G/A/M, complement C3/C4, ESR, and CRP were all normal. She had a positive response to the neostigmine test and the serum level of anti-AchR antibody was 20 nmol/L. Thyroid ultrasound revealed a diffusely uneven echo pattern and a 0.8 x 0.4 cm hypoechoic nodule in the left lobe. Contrast-enhanced chest CT detected an anterior mediastinal mass indicating a thymoma (Figure 1). Oral unstimulated salivary flow rate was 0 ml/min. The presence of dry eyes was confirmed based on the ophthalmic examination. Biopsy of the labial gland revealed focal lymphocytic sialadenitis with a focus score >=1. She was given pyridostigmine bromide 60 mg three times per day.\nOUTPUT:" }, { "from": "agent", "value": "Myasthenia Gravis, Primary Sjögren's Syndrome, Hashimoto's thyroiditis, Type B1 thymoma" } ]

[ { "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 index case (Figure 1, individual II.1) was the first of two brothers, born to a healthy mother (individual I.2) and a father with hyposmia (individual I.1), as the only remarkable family background. His mother was 14 years old by the time of her menarche and her height was 159.7 cm. His father's height was 164 cm, and the adjusted mid-parental height was 168.1 cm (30th centile). His brother (individual II.2), who was 5 years younger than the proband, was a healthy boy with normal genitalia. At the age of 3 months, the index case was referred to our hospital because of micropenis: penile length was 1 cm (-6.4 SDS) and width 0.7 cm (-3.2 SDS). His body length and weight were normal as well as his neurological development. The testicular volume was 1 ml bilaterally, i.e., the lowest limit of normal for age according to Prader's orchidometer. The assessment of the gonadal axis at the time of postnatal physiological activation revealed low serum concentrations of LH and testosterone, AMH in the lower limit of the normal range, and normal plasma concentration of FSH (Table 1). His growth and development were normal during childhood (Figure 1), but his genitalia remained small: at the age of 9 years his penis length was 3 cm (-2.3 SDS). The testicular volume was normal, 2 ml bilaterally. While the serum concentrations of LH and testosterone remained at the low levels expected for age during childhood, the baseline serum concentrations of FSH and AMH caught up to the normal reference values (Table 1).\nOUTPUT:" }, { "from": "agent", "value": "Delayed Puberty, WDR11 Truncation, Mild Form of Ciliopathy, Dissociated Central Hypogonadism" } ]

[ { "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 67-year-old female presented with change in speech, slowness while walking, and forward bending of the spine that had started 1 year prior to presentation. Examination revealed slow hypophonic speech, bilateral bradykinesia, and rigidity. Magnetic resonance imaging of the brain was normal. Other relevant investigations such as the thyroid profile and liver function tests were normal. On review of her medical records, it was found that patient had been taking levosulpiride 75 mg/day for the last 18 months for her dyspeptic symptoms. There was a significant improvement in bradykinesia within 10 days of stopping levosulpiride and starting levodopa/carbidopa (125 mg three times daily). At 6 months, there was significant improvement in her symptoms, and the patient is currently on regular doses of levodopa/carbidopa (Video 1).\nOUTPUT:" }, { "from": "agent", "value": "Camptocormia, Symmetrical Parkinsonism, Diabetic Nephropathy" } ]

[ { "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 man presented to the emergency department for macroscopic hematuria and reduced urinary output. He had previous medical history of diabetes and AS diagnosed 2 years before. Usual medication consisted in glibenclamide, metformin, and infliximab, without recent use of NSAIDs. The patient denied asthenia, dyspnea, cough, hemoptysis, or other relevant complaints including upper respiratory symptoms. On examination, he was afebrile, hypertensive, and anuric with peripheral edema, but without need for supplemental oxygen therapy. He did not show any signs of rash or cutaneous purpura. Lab test revealed AKI with sCr of 6.4 mg/dL and urea of 130 mg/dL. Serum electrolytes, CRP, and albumin were within normal range. Thorax x-ray showed mild pleural effusion and renal ultrasound excluded obstruction. Diuretic therapy was initiated without improvement and the patient was started on hemodialysis. Complementary investigation revealed negative ANCA, anti-glomerular basement membrane, ANA, and anti-dsDNA antibodies. Screening for hepatitis B, C, and HIV were negative, as were other microbiologic studies. Serum electrophoresis was unremarkable. Tubules showed extensive acute tubular necrosis and erythrocyte casts, interstitium revealed only diffuse edema and there were no vascular alterations. Endovenous cyclophosphamide and steroid treatment were initiated (methylprednisolone for 4 consecutive days followed by 1 mg/kg daily oral prednisolone). As the patient remained dialysis-dependent, plasmapheresis was started and a total of 5 sessions were performed without improvement. During the course of the hospitalization, the patient evolved unfavorably due to an infectious complication and eventually died from sepsis one month after admission.\nOUTPUT:" }, { "from": "agent", "value": "Ankylosing Spondylitis, Kidney Disease, Acute Kidney Injury, Globally proliferative glomerulonephritis, Crescentic IgA nephropathy" } ]

[ { "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: Ms. S 40-year-old female, diagnosed case of psychosis not otherwise specified (NOS) since last 19 years and was on tablet clozapine 200 mg/day and tablet amisulpride 200 mg/day since last 7 years. She was compliant to treatment and was maintaining well on this combination. She discontinued clozapine 1 year ago but kept on taking tablet amisulpride 200 mg/day. Around 31/2 months ago, she discontinued amisulpride too and was admitted in psychiatry ward with a recurrence of a problem since last 2 weeks. Her mental status examination revealed delusion of persecution and ideas of grandiosity with absent insight. Her routine blood investigations were within normal limits. Tablet amisulpride was restarted with 50 mg/day and gradually increased up to 400 mg/day, and she was discharged after 2 weeks on tablet amisulpride 400 mg/day in stable conditions. During follow-up visits, she reported involuntary movement of lower jaw (after 2 months of restarting amisulpride). The movements of lower jaw were side-to-side, stereotypic, fast, and continuous in nature. However, these movements would disappeared during sleep and also lessen during the conversation. She was not able to eat properly due to continuous movements and also stopped attending social gathering. The score on Abnormal Involuntary Movement Scale was 16. Tablet tetrabenazine 12.5 mg BD was added and which was gradually increased to 37.5 mg/day over a period of 4 weeks without any improvement in involuntary movement. Currently, she is maintaining well on quetiapine 400 mg/day.\nOUTPUT:" }, { "from": "agent", "value": "Tardive Dyskinesia" } ]

[ { "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 woman with a known 9-mm aneurysm of the right middle cerebral artery (MCA) (Fig. 1a) was found unresponsive after a sudden increase in headache pain. At admission, she was comatose, with a score of 4 on the Glasgow Coma Scale (GCS) and grade 5 on the World Federation of Neurosurgical Societies (WFNS) grading scale (i.e., pupils equal, dilated, and unresponsive to light). At that stage, she was intubated but did not display respiratory distress. Computed tomography (CT) revealed a large fronto-temporo-insular intracerebral hematoma (ICH) on the right side, which displayed a substantial mass effect (Fig. 1b). She underwent an emergency craniectomy and a partial removal of the hematoma to decrease the intracranial pressure. No improvement was observed after the surgery, and the patient was not qualified for subsequent aneurysm obliteration. The patient died 2 days later. Before admission, the patient reported a 4-week history of headaches in the right temporal area, sometimes with nausea. This was the indication for performing CT, magnetic resonance imaging, and computed tomography angiography. After the UIA diagnosis, active treatment was offered, because she was young and a smoker, the aneurysm was multi-lobulated, and its diameter exceeded 7 mm. She was qualified for semi-elective surgery at the soonest available date (2 weeks after the UIA diagnosis) at our department. She had also been informed about the possibility of treatment in other neurosurgical departments. Seven days before the planned surgery, the aneurysm ruptured.\nOUTPUT:" }, { "from": "agent", "value": "Unruptured Intracranial Aneurysms, Aneurysmal Hemorrhage" } ]

[ { "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 73-year-old Japanese male had been followed at our outpatient clinic for apical HCM for 3 years. His previous medical history included dyslipidaemia and polymyositis. There was no family history of cardiovascular disease or sudden cardiac death. In a steady state, he complained of mild exertional dyspnoea with New York Heart Association functional Class II. Electrocardiography shows sinus rhythm, LVH with ST depression, and T wave inversion (maximum depth of 6 mm in V5 lead) in lateral leads (I, aVL, and V4-V6 leads) (Figure 1A, left). Echocardiography shows a LV ejection fraction of 72%, diffuse LVH in the apex (maximum LV wall thickness of 15 mm), and papillary muscle hypertrophy (Figure 2). These findings were consistent with apical HCM. During follow-up, he was admitted to our outpatient clinic for chest discomfort. On physical examination, the fourth heart sound was auscultated. Electrocardiography shows sinus rhythm and disappearance of the negative T wave in V4-V6 leads (Figure 1A, middle). Echocardiography showed LVH and normal LV wall motion without segmental LV hypokinesis, findings that were not significantly different from those in the previous examinations. Laboratory examinations showed a creatinine kinase (CK) level of 107 U/L (normal range of 59-248 U/L) and a high-sensitivity cardiac troponin T (hs-cTnT) level of 0.034 ng/mL (normal range of <0.014 ng/mL). Therefore, coronary angiography (CAG) was performed that revealed a severe stenotic lesion (99% stenosis) of the mid-LAD, and percutaneous coronary intervention (PCI) was performed with drug-eluting stent (Figure 1B). After the intervention for the LAD, his symptom was relieved and ECG showed mild T wave inversion. After 6 months, the T wave returned to a negative T wave with the previous depth (maximum depth of 7 mm in V5 lead) (Figure 1A, right).\nOUTPUT:" }, { "from": "agent", "value": "Apical Hypertrophic Cardiomyopathy, Left Anterior Descending Artery 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: Case: A 37 years old woman complaining of gastrointestinal symptoms compatible with irritable bowel syndrome (IBS) of moderate-intensity, diarrhea, and bloating predominant performed the GIP tests during flare-ups of symptoms. She reported a positive test out of 5 after eating at a social event (an office Christmas party). However, the other tests were negative despite the flare-ups of gastrointestinal symptoms. Case: A 49 years old man referring onset of IBS diarrhea type after a stressful life event. A complete workup was offered, including upper and lower endoscopy with histology, laboratory tests, abdominal ultrasound scan. He worked as a tour guide and was persuaded that GI symptoms were related to gluten contamination of his meals at restaurants. His work was compromised, and he agreed to undergo testing for GIP after eating out. None of the five tests was positive. He felt reassured that his symptoms were not related to his diet but a stressful life event with consequent behavioral changes. Case: A 17 years old classic ballet dancer who received the CeD diagnosis in infancy. She was referred to our center because of her low body weight. She reported three positive GIP tests out of 5. After completing the observation period, she admitted voluntary daily gluten intake with the specific aim to provoke malabsorption and weight loss, to maintain the proper silhouette. After that, she was referred to psychological counseling. Cases: during the lockdown days for the COVID-19, two patients originally not included in the study called in for a remote consultation visit. They both were health-care givers with CeD, working in COVID Hospitals. They were worried about the possible contamination of their GF meals provided, during the crisis, from the hospital canteen. We could send them three tests each, and all resulted in negative. After completing the study, five worried patients returned to their hospital canteen without fear of the possible gluten contamination of food. One patient asked to have an additional GIP test to take with her on a trip abroad \"just to stay on the safe side.\"\nOUTPUT:" }, { "from": "agent", "value": "Coeliac 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 twenty year-old female presented to our clinic with complaints of worsening fecal incontinence coupled with a history of intermittent constipation. She did not have vertebral, cardiac, trachea-esophageal, renal, or limb defects (VACTERL Association). From the age of 12, she had suffered from persistent constipation requiring digitalization, frequent enema usage and oral laxative administration (Fig. 1). Her Cleveland Clinic Constipation Score (CCCS) was 28. On exam she had a patulous anus with mild anal stenosis and mucosal prolapse with poor resting/squeeze tone along with a thin perineal body. Anal manometry revealed low resting (29.6 mmhg) and squeeze (60.3 mmhg) pressures, along with low compliance. Endoanal ultrasound showed a normal puborectalis sling with an attenuated but intact internal sphincter and external sphincter. Flexible sigmoidoscopy was significant for mild anal stenosis; otherwise the descending colon, sigmoid and rectum were normal. The patient's incontinence was her most significant problem as it was negatively affecting her quality of life. Her pre-SNS Fecal Incontinence Quality of Life (FIQOL) scale was most notable in regards to lifestyle alteration (1.1), poor coping and behavior (1), along with depression and poor self perception (2.5). Although weak, her sphincters were intact, and thus she was not a candidate for sphincteroplasty. Therefore we offered her sacral nerve stimulation for the primary treatment of incontinence with a secondary goal of treating her constipation.\nOUTPUT:" }, { "from": "agent", "value": "Bowel dysfunction from imperforate anus" } ]

[ { "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 received one cycle of induction chemotherapy containing cisplatin (CDDP) (100 mg m-2) day 1 and 5-FU 12-h c.i. (1000 mg m-2 day-1) for 5 days, every 3 weeks. Approximately 95 h after beginning the first cycle of 5-FU infusion, the patient referred several episodes of anginal pain, associated with sweating, that disappeared with oral nitroglycerin. and the EKG recorded shortly after pain remission showed ischaemic alterations. The patient was admitted to the hospital and immediately subjected to an echocardiogram that revealed a reduction in inferior and posterolateral contractility and an altered left ventricle diastolic release with an ejection fraction of 56%. The EKG recorded the following day showed a T-alteration in the anterolateral leads and a nonspecific ST segment elevation in the inferior leads. At 4 days after the pain episode, the EKG showed a T-alteration in the lateral leads, likely due to an AMI with ischaemic alterations. The effort-EKG obtained on the same day was interrupted at 80% of the maximum because ventricular extrasystole bigeminis rised. The patient was subjected to CT-scan for restaging of disease. This showed a 50% reduction of pulmonary metastases and disappearance of abdominal lymphatic metastasis. For this reason, the same chemotherapy infusion schedule was continued, but the dose of 5-FU was reduced to 800 mg m-2 day-1. Transepidermal nitroglycerin was administered during 5-FU infusion and chemotherapy was administered while the patient recovered at the hospital. The dose of 5-FU for the cycles thereafter was increased to 900 mg m-2 day-1 with transepidermal nitroglycerin administration during 5-FU infusion. The patient received a further four cycles of this treatment, in an outpatient setting, and no longer complained of anginal pain.\nOUTPUT:" }, { "from": "agent", "value": "5-fluorouracil-associated cardiotoxicity, ampulla of Vater adenocarcinoma, high blood pressure, diabetes, gastritis" } ]

[ { "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 had no evidence of sepsis and other co-morbidity. Her hematological and biochemical investigations were within the normal range. Urinalysis revealed occasional pus cells and the serum creatinine was 0.9 mg% and serum biluribin was 0.6 mg%. Ultrasonography of the abdomen revealed that both kidney were normal in size, maintained echotexture and had preserved cortico-medullary differentiation. There was no evidence of lymphadenopathy, ascites and liver metastasis. A standard technique of in situ perfusion during organ procurement was used. Briefly, midline laparotomy and thoracotomy was performed. The infra-renal and supraceliac aorta were dissected. In situ perfusion was performed with histidine-tryptophan-ketoglutarate solution, blood and fluid were exsanguinated in the chest. Abdominal organs were cooled by ice-slush at the time of in situ perfusion and then procured. Both the recipients agreed upon accepting the organ at the first instance when they were counseled regarding the availability of a deceased donor harboring brain tumor and possible risk of cancer transmission, and transplantation was carried out on 24 November 2013. Both recipients received induction with rabbit-anti-thymocyte globulin (r-ATG) (1.5 mg/kg) and methylprednisolone (MP) 500 mg intravenously. MP was continued for 3 days post-operatively. Maintenance of immunosuppression consisted of prednisolone (30 mg/day tapered to 10 mg/day at 3 months post-transplant and continued thereafter), mycophenolate mofetil (2 g/day) and tacrolimus (0.08 mg/kg body weight/day). Both recipients also received prophylaxis against cytomegalovirus infection (gancyclovir 1 g thrice a day x 3 months), fungal infections (fluconazole 100 mg once a day x 6 months) and Pneumocystis carinii pneumonia (trimethoprim/sulfamethaxazole [160/800 mg] once a day x 9 months).\nOUTPUT:" }, { "from": "agent", "value": "Recurrent non-operable, large, low-grade astrocytoma" } ]

[ { "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 72-year-old woman underwent LC due to symptomatic gallstone disease. Her past medical history was uneventful. Intraoperatively, the gallbladder was perforated resulting in bile and gallstone spillage into the peritoneal cavity. The abdominal cavity was irrigated with 1 lt of normal saline to dilute and aspirate bile and gallstones; however the retrieval of the spilled gallstones was incomplete as a combined result of their large number and small size. The postoperative course of the patient was uneventful. Six months postoperatively, the patient presented to our department complaining of high fever (body temperature up to 39.2 C), chills, and constant pain in the right lumbar region for two days. On clinical examination the right hypochondrium and right lumbar region were both tender. Blood tests revealed white blood cell count 13.200/mL, neutrophils 87.3%, and C-reactive protein 14.9 mg/dL (normal value <0.5 mg/dL). The patient was given intravenous antibiotics (ciprofloxacin 400 mg x2 and metronidazole 500 mg x3) for seven days, and afterwards she was discharged from hospital in good condition, entering an intensive follow-up program.\nOUTPUT:" }, { "from": "agent", "value": "Retroperitoneal 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: A 78-year-old male patient with history of high blood pressure, a renal tumor that underwent partial nephrectomy, and a carcinoma in situ in the glans was treated by resurfacing. During the follow-up, the patient reported perineal and penile pain of months of evolution. The imaging tests performed revealed an abscess with a solid pole in the infrapubic region that affects the left corpus cavernosum. In the extension study, multiple indeterminate pulmonary nodules were identified. In the preoperative study, a significant growth of the perineal mass was observed, reaching 75 mm in its maximum diameter and affecting the left ischiopubic branch, adductor muscles, and ipsilateral gracilis. Pathological left inguinal lymph nodes were also observed. Penile exploration and negative glans biopsy ruled out possible recurrence of penile carcinoma. The case was discussed in the multidisciplinary tumor committee, and the surgical treatment was decided. The patient underwent total penectomy, resection of left isquiopubic branch, and partial resection of adductor muscles of the thigh and left inguinal lymph node dissection. The perineal defect was covered with a contralateral gracilis flap. The patient required postoperative wound debridement due to partial necrosis of the wound. The patient was discharged 3 weeks after the intervention with good functional recovery. Inguinal lymph node dissection showed one metastatic node of the six resected. The patient received adjuvant chemotherapy treatment with cisplatin and 5-FU. After 17 months of follow-up, the patient presented pulmonary progression of the disease under treatment with the fourth line of chemotherapy treatment.\nOUTPUT:" }, { "from": "agent", "value": "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 36-year-old woman who emigrated from the Ecuador in 2002 presented to the emergency department with a one-year history of intermittent abdominal pain, diarrhea, and a 70-pound weight loss. She had no reported medical history, recent travel outside of the US, or known sick contacts. She appeared cachectic with diffuse muscle wasting and had a body mass index (BMI) of 14. Initial labs were notable for a white blood cell count 4.5 k/mm3, hemoglobin 8.8 g/dL, iron 17 mcg/dL, TIBC 47 mcg/dL, ferritin 123 mug/L, C-reactive protein 9.4 mg/dL, HIV negative, anti-nuclear antibody screen negative, anti-myeloperoxidase antibody negative, anti-perinuclear-3-antibody negative, and albumin 1.8 g/dL. Computed tomography (CT) of the chest and abdomen showed several right-sided pulmonary nodules, a large left-sided pleural effusion, and diffuse small and large bowel wall thickening with enlarged mesenteric lymph nodes. EGD revealed atrophic mucosa throughout the stomach and proximal duodenum. Esophageal, gastric, and duodenal biopsies were unrevealing. Colonoscopy showed circumferential friable ulcerated mucosa in the descending colon (Figure 3). The colonoscope was not advanced beyond this area. Biopsies showed necrotic tissue that was negative for acid-fast bacilli (AFB). Extensive autoimmune and infectious workup was unrevealing. Stool culture was positive for acid-fast bacilli. There was no inflammation or pathology in the terminal ileum.\nOUTPUT:" }, { "from": "agent", "value": "Gastrointestinal Tuberculosis, Malnutrition, Distal Colonic Bowel Obstruction" } ]

[ { "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 fifty-one year old female patient with history of diabetes mellitus and systemic lupus erythematoses (SLE) complicated by lupus nephritis. Although we have included her case in our previous publication, we have not reported her clinical details at that time. She was put on prednisolone 30 mg and azathioprine 100 mg daily since end of June and mid-July 2002, respectively. She was admitted to Queen Mary Hospital on 11th August 2002 for investigation of jaundice. Investigations revealed deranged liver function tests with cholestatic pattern. A diagnosis of drug-induced hepatotoxicity was entertained, and azathioprine was stopped after admission. As her autoimmune disease was under control, her steroid dosage was reduced from 25 mg to 15 mg daily within the next 14 days. Her CXR taken on admission was normal. Soon after her immunosuppressive therapy was tapered, she developed fever and non-productive cough. A repeat CXR performed on 9th Sept revealed new infiltrate over the left mid-zone, suggestive of pneumonia. She was started on intravenous ceftazidime 1 gram eight hourly and oral clarithromycin 500 mg twice daily. Serial CXR performed three days later showed increasing bilateral pulmonary infiltrates and worsening hypoxemia. There was an upsurge of total lymphocyte count from 0.7 x 109/L (total white cell count 7.2 x 109/L) at the time of admission to 5.6 x 109/L (total white cell count 10.8 x 109/L) at the time of clinical deterioration. Bronchoscopy with transbronchial biopsy performed on the same day revealed Pneumocystitis jiroveci by methenamine sliver stain. Workup for other opportunistic pathogens including cytomegalovirus and aspergillus was negative. She was commenced on intravenous pentamidine (4 mg/kg/day) and corticosteroids for severe PCP infection. Despite active treatment she developed progressive respiratory failure and required admission to intensive care unit. She subsequently recovered after a stormy hospital course, and upon discharge from hospital, her total lymphocyte count had returned to her baseline of 0.86 x 109/L.\nOUTPUT:" }, { "from": "agent", "value": "Pneumocystis jiroveci 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: Oxygenation index (OI) was noted to decrease following vasopressin initiation, most notable after 12 h of exposure (mean 25.10 +- 24.14 to 11.36 +- 4.67, Table 2). One patient had rebound in OI associated with rewarming phase of therapeutic hypothermia (Figure 1). MAP improved at 1 h of vasopressin exposure (mean 44.50 +- 7.80 to 57.90 +- 13.27 mm Hg). There was a decrease in mean inotropic score (IS) at 12 h (24.70 +- 12.94 to 10.5 +- 10.25). Mean vasoactive-inotropic score (VIS) decreased gradually, lowest at 24 h (25.50 +- 12.78 to 16.57 +- 8.45, Table 2). Five patients (50%) averted ECMO, and all had vasopressin therapy for >12 h. Of those who required ECMO, only one out of five received vasopressin for >12 h.\nDespite a down-trending heart rate from mean of 146 beats per minute (bpm) to 130 bpm after 6 h of vasopressin, there was a concurrent worsening lactic acidosis with peak of 4.65 +- 3.16 at 6 h (Table 2). This was followed by a gradual decrease at 48 h with mean lactate of 2.1 +- 0.56. There was no notable change in urine output. Transient hyponatremia was appreciated after 12 h of vasopressin (135.90 +- 1.87 to 130.33 +- 3.50 mmol/L) with nadir identified at 24 h (126.20 +- 4.49 mmol/L) and subsequent improvement by 72 h (134.22 +- 9.71 mmol/L). There were no cases of necrotizing enterocolitis. Three (30%) required a gastrostomy tube and nine (90%) were discharged in room air with one (10%) requiring low flow oxygen via nasal cannula. All neonates survived to discharge.\nOUTPUT:" }, { "from": "agent", "value": "Persistent pulmonary hypertension of the newborn" } ]

[ { "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 40-year-old female from Ralegaon village, Yavatmal district, farm laborer by occupation was admitted in drowsy state with history of fever for 10 days, cough and progressive shortness of breath for last 5 days, and pain in right side of abdomen and vomiting for last 3 days. On general physical examination, she was febrile (39.2 C), icteric, and drowsy. She had pulse of 114 beats per min, blood pressure of 110/80 mmHg, and respiratory rate of 26 breaths per min. Her GCS score was E2M5V4. A 1.5 cm sized black crusted ulcer (eschar) was found on the lateral aspect of right thigh [Figure 3]. Her chest examination revealed bilateral crackles. Chest radiograph showed bilateral diffuse infiltrates [Figure 4]. She was treated with oral doxycycline 100 mg twice a day. Arterial blood gas analysis revealed metabolic acidosis and PaO2/FiO2 ratio of 54. Her laboratory investigations revealed TLC of 21,300 mm3, hemoglobin of 7.8 gm/dl, and platelet count of 116,000 mm3; AST, 373; ALT, 238; total bilirubin, 3.6 mg/dl; albumin, 1.7 gm/dl; total protein, 4 gm/dl; creatinine, 2.4 mg/dl; and urea, 84 mg/dl. CSF examination did not reveal any abnormality. Abdominal USG was normal. Her Weil-Felix test was positive for the OX-K antigen in titers of 1:320. Biopsy of eschar showed a lymphohistiocytic vasculitis, perivascular collections of lymphocytes with areas of ulceration, and necrosis of overlying epidermis.\nOUTPUT:" }, { "from": "agent", "value": "Scrub typhus, Acute respiratory distress syndrome, Multiorgan failure" } ]

[ { "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 first three episodes had been treated elsewhere, each time presenting with headache, fever, photophobia but no rash. Though no bacterial diagnosis was ever made and no organism isolated, his episodes were associated with high cerebrospinal fluid (CSF) protein and CSF neutrophil infiltrate. He responded well to intravenous antibiotic treatment on each occasion with no neurological deficit. He did report some non-specific upper respiratory tract symptoms but none suggestive of CSF rhinorrhoea. The rest of his humoral and cellular immune tests were normal. This was confirmed at surgery. The defect was surgically repaired with temporalis fascia and inferior turbinate mucosa by an endonasal endoscopic route.\nOUTPUT:" }, { "from": "agent", "value": "Recurrent meningitis, Staphylococcus aureus infections, low mannose-binding lectin (MBL) levels, defect in the cribriform plate, meningocoele" } ]

[ { "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: Irinotecan has been studied clinically as monotherapy and in combination with bevacizumab for recurrent HGG. As monotherapy it has been shown to have a median PFS of approximately 2.7 months which increases to approximately 4.8 months (3.7-5.6) when used in combination with bevacizumab. He subsequently underwent standard concurrent chemoradiation with TMZ, followed by an abbreviated course of adjuvant TMZ with disease progression after 5 months. He underwent re-resection with tissue submitted for 3D Predict Glioma which revealed a response to irinotecan. He was placed on irinotecan/bevacizumab, which he tolerated well for 8 cycles. He did experience radiographic progression with punctate areas of enhancement noted in the surgical cavity at 6 months. These relatively small areas of progression were treated with gamma knife radiosurgery. He continued combination irinotecan/bevacizumab with excellent tolerance for an additional 3 months, at which point treatment was discontinued due to further progression and declining performance status. Importantly, his PFS of 6.7 months exceeded that of those published for irinotecan with bevacizumab (Figure 6E and F). For some patients, targeted therapies for specific genetic mutations have proven successful in solid tumors. However, many of these therapies are not efficacious in HGG. Importantly, some patients benefit from these therapies without harboring the targeted mutation, demonstrating the limitations of NGS for personalized medicine and suggesting alternative signaling pathways not yet identified or described. Assays that measure functional response may identify those patients not recognized by NGS. During this observational study, 2 patients were identified by 3D Predict Glioma as responding to the BRAF inhibitor vemurafenib (Figure 6G). Since dabrafenib has an improved ability to cross the BBB, both patients received dabrafenib as their treatment.\nOUTPUT:" }, { "from": "agent", "value": "High-grade gliomas, IDH-wild type GBM" } ]

[ { "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 January 2012, a 50-year-old postmenopausal woman was referred to our department, for the past 2 years she had noticed a palpable node in her right breast. Extensive stage T3N3 breast cancer with multiple bone metastases was diagnosed. Histopathological examination revealed grade 3 invasive ductal cancer, ER/PgR (Allred scores 8/8) and HER2 IHC 3+ positive. As first-line treatment, letrozole plus trastuzumab was initiated. During treatment, the tumor markers (CA15-3 and CEA) increased and 5 months later skeletal progression was detected. Then, following four courses of doxorubicin plus cyclophosphamide, paclitaxel (once every 3 weeks) was initiated. Tumor markers decreased to normal levels and partial response was detected at all metastatic sites, however, due to grade 3 peripheral neuropathy, paclitaxel treatment was terminated after 18 cycles. Then, fulvestrant (loading and then high-dose schedule, 500 mg every 14/28 days) was introduced as maintenance therapy. After 19 months of fulvestrant therapy, the patient presented with CNS symptoms; brain CT verified multiple metastatic lesions in the cerebellum and parieto-occipital region. Whole brain irradiation with simultaneous integrated boost (14x 2.2 Gy+14x 0.8 Gy) was applied. Since all the extracranial tumor manifestations were controlled with fulvestrant, the patient remained on the systemic therapy; following another 14 months of fulvestrant therapy, no progression was detected until June 2017. At that time, although the brain metastases remained stable, new metastases in the liver and spleen, as well as progression of the bone metastases were diagnosed. The patient's general condition deteriorated continuously and she died in September 2017 (Figure 1).\nOUTPUT:" }, { "from": "agent", "value": "Hormone receptor and HER2 positive advanced 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: The patient received intravenous teicoplanin and meropenem, with voriconazole to prevent fungal infections empirically at first. When the child's condition was still getting worse, the antimicrobial drugs were switched to tigecycline and cefoperazone/sulbactam. The patient condition improved after antibiotic conversion. The antimicrobial susceptibility test results showed sensitivity to tetracycline, which was consistent with the improvement in the patient's symptoms. The patient was discharged 4 weeks after transplantation. The species was identified using the Phoenix 100 Automated Microbiology System (Becton-Dickinson, New Jersey, USA), reidentified by matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF-MS) with using a Microflex LT mass spectrometer (Bruker Daltonik), and analyzed using MALDI Biotyper (Bruker Corporation, Massachusetts, USA). The minimal inhibitory concentrations (MICs) of the CRE strain were measured using the Phoenix 100 Automated Microbiology System and interpreted using the Clinical Laboratory Standards Institute criteria (CLSI, 2019), except for polymyxin, which was interpreted using the European Committee on Antimicrobial Susceptibility Testing criteria (EUCAST, 2019). Nineteen antibiotics belonging to 11 classes of antimicrobials were used for susceptibility tests in this study, including penicillins (ie, ampicillin), beta-lactam/beta-lactamase inhibitor complexes (ie, amoxicillin-clavulanate, ampicillin-sulbactam, and piperacillin-tazobactam), aminoglycosides (ie, gentamicin and amikacin), monocyclic beta-lactams (ie, aztreonam), chloramphenicols (ie, chloramphenicol), cephalosporins (ie, cefazolin, cefotaxime, ceftazidime, and cefepime), carbapenems (ie, imipenem and meropenem), fluoroquinolones (ie, ciprofloxacin and levofloxacin), folate metabolic pathway inhibitors (ie, trimethoprim-sulfamethoxazole), tetracyclines (ie, tetracycline), and colistin.\nOUTPUT:" }, { "from": "agent", "value": "Acute myeloid leukemia-M7, Carbapenem-resistant K. oxytoca strain wzx-IMP" } ]

[ { "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 25-year-old Chinese man with fever and acute left chest pain visited our emergency department. He was diagnosed with syphilis and started oral amoxicillin/clavulanate three days ago. He occasionally smoked one or two cigarettes a day. No travel history within six months or illegal drug use were identified. On admission, his body temperature was 39.4 C, blood pressure was 128/59 mmHg, and oxygen saturation on room air showed 96%. An auscultation of the left chest showed coarse crackles. His chest pain worsened during inspiration. The electrocardiogram revealed heart rate of 93 beats per minute and no ST-T change was observed. The chest X-ray showed an infiltrative shadow in the left lower lung field and chest CT revealed the consolidation along with ground-glass opacity in the both lung fields and pleural effusion (Fig. 1a and b). The laboratory findings showed the neutrophil-dominant increase of white blood cell counts (9550/muL) and increase of C-reactive protein (7.96 mg/dL). The cultures for blood and sputum showed negative results. Other laboratory data were mostly within normal limit (Table 1). Combined with the clinical symptoms and radiological findings, his initial diagnosis was bacterial pneumonia with pleuritis. Piperacillin/Tazobactam was initiated, but his symptoms gradually worsened. 2). D-dimer was increased to 26.1 mug/dL (Table 2). Although he had denied the history of any casual sex contacts on admission, he confessed that he was men who have sex with men (MSM) after careful interview. Evaluation of deep thrombosis by the lower limb echo showed no evidence of venous thromboembolism. The heart ultrasound indicated normal left ventricular contraction with no right heart load. After initiation of an anticoagulant therapy (edoxaban 60 mg/day), his symptoms and radiological findings gradually improved (Fig. 3). Although his CD4+ lymphocyte counts were decreased to 40/muL, he showed no evidence of opportunistic infection. He started antiretroviral therapy after discharge.\nOUTPUT:" }, { "from": "agent", "value": "Pulmonary Infarction, HIV" } ]

[ { "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 hospitalized three months ago for dysphagia. CT chest that admission revealed a right-sided pleural effusion and mediastinal mass (Fig. 1). An EndoMAXX fully covered metallic esophageal stent was placed to palliate dysphagia, after which she quickly developed dyspnea and hypoxemia in the subsequent days. Repeat CT chest three days after stent placement revealed an increase in the right-sided pleural effusion and a new, small left-sided pleural effusion (Fig. 2). Diagnostic thoracentesis that admission yielded an exudative, lymphocyte-predominant effusion. The effusions were deemed secondary to lymphedema from prior right-sided mastectomy and axillary lymph node dissection. On physical exam this admission, she was sitting upright in a tripod-position with respiratory distress. Decreased breath sounds were noted over the entire right hemithorax, and over the left hemithorax to the mid-lung field. Laboratory findings were significant for normal WBC count, age-appropriate pro b-type natriuretic peptide, and negative cultures. CT chest revealed large, right greater than left, pleural effusions. Throughout her hospital course, she had persistent output of more than 500 mL daily from the right-sided catheter. Her admission CT chest was reviewed, and the thoracic duct was noted to be impinged by the esophageal stent (Fig. 3). The Gastroenterology team subsequently retracted the stent proximally by 2 cm. Post-operatively, the rate of fluid accumulation on the right decreased remarkably. The patient had a prolonged hospitalization complicated by malignant biliary obstruction and cholangitis. Progression of her malignancy and inability to tolerate diagnostic and therapeutic procedures due to severe deconditioning led to her eventual demise.\nOUTPUT:" }, { "from": "agent", "value": "Recurrent chylothorax, Metastatic 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: A 2-year-old white boy presented to our clinic with frequent coughing episodes since 6 months of age. On presentation, a daily, mostly dry cough had been present for most of the preceding 12 months, exacerbated when running and when lying flat at night. His mother had to put 2 pillows under his head before he could sleep. Occasionally, mild wheeze was noted on auscultation. Daily inhalation with salbutamol and ipratropium bromide brought modest relief. On 2 occasions, cough was accompanied by fever but without tachypnea or crackles. On these 2 occasions, treatment with antibiotics cefaclor and cefuroxime did not stop the cough. On 2 further occasions, cough was accompanied by rhinorrhea. One month of montelukast (a leukotriene receptor antagonist) and later 3 months of twice-daily inhalations with fluticasone (a glucocorticoid) 50 mug brought no improvement to his cough. His mother described that he would often gag during meals and at night would smack and swallow from apparent regurgitation. He continued to develop well, following growth curves along the 50th percentile for height and 75th percentile for weight. The boy began daycare when he was 2 years old. The child had been born by vaginal delivery after an uneventful, full-term pregnancy and had been breastfed for the first 5 months, supplemented with formula from the age of 6 weeks. Significant regurgitation was noted from a few days of life until cessation at 6 months of age. His mother reported an almost constant dribbling of milk from the angle of his mouth and occasional projectile vomiting after feedings. Thickening of formula was not tried. He became a \"colicky\" baby with considerable crying between 2 weeks and 5 months of age, but he slept well at night and had no additional feeding difficulties. Psychomotor development was normal. He crawled at 8.5 months, walked at 14.5 months, and began talking by the age of 2 years. He received all routine German vaccinations except the rotavirus vaccination.\nOUTPUT:" }, { "from": "agent", "value": "Asthma and Gastroesophageal Reflux 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 35 year old unmarried female patient presented to us with abdominal pain. On examination, a vague mass was palpable in the left lumbar region. Computerized tomographic scan of the abdomen and pelvis showed a 9 x 7 cm uniformly solid mass with poor contrast enhancement situated in the inferomedial aspect of the left kidney [Fig 1A]. It was difficult to determine whether the mass was arising from renal parenchyma or renal pelvis. There were no retroperitoneal lymphnodes. Urine cytology, cystoscopy and retrograde ureterography were normal. There was no evidence of distant metastases. The patient also had a pelvic adnexal mass. On abdominal exploration, there was a well defined mass arising from the inferior and anterior aspect of the left renal pelvis, and attached to it with a narrow pedicle. There was no adherence or attachment to the renal parenchyma [Fig 1B]. The renal pelvis was opened to remove it completely. There was no intrapelvic growth. The part of the renal pelvis (about 1.5 cm) from which the tumor was arising was excised. Frozen section revealed a benign nature. The renal pelvis was closed after inserting a double J stent into left ureter. The left adnexal mass was excised with preservation of uterus and other ovary. On pathological examination, the tumor was well-defined and capsulated. On cut section it had a firm, whitish solid appearance without areas of necrosis or hemorrhage. Microscopically, the tumor was composed of large collagenized areas containing bundles of spindle cells. These areas were interspersed with thick walled, blood vessels, fatty tissue and several 'microcysts' lined by cuboidal epithelium [Fig 2A, B]. Normal renal parenchyma was not seen. Immunohistochemistry showed strong positivity for SMA and desmin in the spindle cell areas. Cytokeratin (CK) and epithelial membrane antigen (EMA) were positive in cells lining the microcysts. Estrogen receptor (ER), Progesterone receptor (PR) and HMB 45 (Human melanoma antibody) were negative. After one year of follow up, the patient was well with no adverse effects from the surgery.\nOUTPUT:" }, { "from": "agent", "value": "Benign mixed epithelial stromal tumor of the renal pelvis, Mature cystic 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: An 11-months-old girl with unremarkable medical history, who had received two doses of 7-VCV, presented with chief complaint of 10 min partial seizure involving left hemi-face. Three days prior to presentation she had developed high fever (40 C) that was associated with diarrhea and vomiting. Seizure activity had ceased upon arrival on emergency ward and was soon after followed by another generalized seizure lasting 45 min and requiring 5 mg intra-rectal diazepam and 0.2 mg intravenous clonazepam to resolve. On admission, a post ictal left facial paralysis was noted, which spontaneously resolved 3 h later. Clinical examination revealed bilateral acute otitis media. Initial work-up showed mildly raised Creactive protein (CRP 54 mg/L), white blood cell (WBC) count 25.3 G/L with 13.5% immature granulocytes. The child's neurological status remained seriously impaired with Glasgow Coma Scale (GCS) of 9, and left-sided hemi paresis. The second laboratory work-up showed a CRP of 260 mg/L, WBC 12.0G/L and 42% immature forms. Cerebral computed tomography (CT)-scan showed severe rightsided brain edema with significant deviation of midline structures to the left. A dose of 100 mg/kg of Ceftriaxone was administered and the child transferred to Pediatric Intensive Care Unit (PICU) where her condition worsened with hemodynamic instability and GCS of 4, needing mechanical ventilatory support and vasopressive therapy. Microbiologic cultures were positive for Streptococcus pneumonia serotype 1 [blood, urines, cerebrospinal fluid (CSF) and nasopharyngeal secretions]. The child died on day 6.\nOUTPUT:" }, { "from": "agent", "value": "Invasive pneumococcal infection, Atypical febrile seizure, Purulent meningitis, Multiple brain abscesses, Diabetes insipidus" } ]

[ { "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 56-year-old man initially presented with numbness in the feet and distal legs with associated sensory ataxia. He later developed sensory symptoms in the hands. Of note, the patient had potential exposure to toxic chemicals in his youth but with no reported radiation exposure. He had a paternal cousin with WM as well as a brother who had non-Hodgkins Lymphoma (NHL) treated to remission. Neither of these cases suffered with neuropathy. Nerve conduction studies showed findings typical of anti-MAG neuropathy, with conduction velocities within the demyelinating range and disproportionately prolonged distal motor latencies. He was found to have an IgM paraprotein, and anti-MAG titre at diagnosis was 64,300 BTU. Haematological work-up with bone marrow biopsy and CT body scan showed a clonal B-cell population but with <10% infiltration so categorizing as MGCS rather than NHL. His symptoms worsened over a 10-year period, progressing to disabling unsteadiness. He commenced treatment with standard 5-day courses of intravenous immunoglobulins. Improvement was initially noted but progressively less sustained. Repeated neurophysiological studies remained largely unchanged. The patient was commenced on CIT and achieved a good neurological and serological response. Nine months post-treatment completion the patient presented with rapid cognitive decline and behaviour change. 2). 3). Immunohistochemical staining with GFAP was positive, and Ki67 proliferation index was high with no expression of mutant IDH1 detected. In view of the guarded prognosis, treatment was limited to palliative radiotherapy; however, the patient died 2 months following the surgery.\nOUTPUT:" }, { "from": "agent", "value": "Glioblastoma, IDH-wildtype; IgM Paraproteinaemic Neuropathy" } ]

[ { "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 Z., 71-year-old male, presented with a 2-week complaint of general malaise, increased fatigue, mild headache, and episodes of short-term dizziness not complicated by fall. According to relatives, memory for current events decreased, and short-term (up to a minute) episodes of loss of consciousness appeared (up to several times a day), during which the patient froze and did not come into contact with others. In addition, the difficulties in communication intensified with the appearance of periods of reasoning. The general malaise and dizziness had progressed, and a hypertensive crisis on 6 February 2018 led to admission to the internal medicine department with a diagnosis of cerebrovascular disease. The condition did not improve after 2 weeks of symptomatic therapy, and the patient was transferred to outpatient treatment. When the MRI of the head was performed in the FLAIR mode, a lesion in the medial parts of the left temporal lobe was detected (Figure 4). On admission, the condition was relatively satisfactory, the consciousness was clear, the understanding of reversed speech was difficult, and there were exaggerated tendon and periosteal reflexes with the expansion of reflexogenic zones, Rossolimo's sign positive bilaterally, and easily expressed instability in Romberg's position. CSF contained a significantly increased protein content (1.1 g/L), erythrocytes (250 x 106/L cells), and predominantly lymphocytic pleocytosis (up to 23 x 106/L cells); no antibodies to NMDAr were detected. Herpetic infection (IgM, IgG) was ruled out. The EEG (30 March 2013) demonstrated a periodic regional slowdown in the leads Fp1-F7 (Figure 5). At the same time, in the contralateral area (leads Fp2-F8), a regional BDP (beta-delta brush) was recorded (Figure 6). In the period of hospital stay:5 April 2018:there was a single BTCS, which entailed the appointment of VPA in a dose of 600 mg/day per os. In the repeated EEG from 6 April 2018, the marked changes regressed (Figure 7). After treatment with GC (methylprednisolone) IV and plasmapheresis, the patient's well-being improved, the symptoms completely regressed, and the attacks did not recur. The patient was discharged home for outpatient follow-up with recommendation to continue treatment with VPA.\nOUTPUT:" }, { "from": "agent", "value": "Limbic Encephalitis" } ]

[ { "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 also had complained of paresthesia and gait disturbance since one month before admission. Neurological exam revealed the force of 4/5 at upper extremities and spastic paraparesis (proximal forces 3/5 and distal forces 4/5) and hypesthesia to pinprick and light touch. Deep tendon reflexes were increased, and plantar responses were extensor bilaterally. There were no bowel or bladder symptoms. Dynamic lateral x-rays and magnetic resonance imaging (MRI) were done, and occipitocervical instability was diagnosed. The patient underwent OCF with an occipital plate and lateral mass screws at C3 and C4. Gradually, over one year, all the symptoms were revealed, and the patient backed to his work. After six years, the patient was referred to our center with the complaint of wound discharge. Lab data including erythrocyte sedimentation rate, C-reactive protein, and complete blood count were investigated, blood and wound culture were provided, and further sepsis workups were done. According to our lab findings, no infection was found. Moreover, all the inflammatory findings were within the normal range. The patient was also complaining of recurrence of previous symptoms such as gain difficulty and hypesthesia over the last six months. A lateral dynamic x-ray was taken, which showed possible instability. Computed tomograph scan was done that showed the failure of the fusion construct (Figure-1). The patient underwent surgical exploration, and we found that all instruments are quite loose. All of them were removed, and a halo vest was fixed for the patients. The culture from instruments was negative, but the patient underwent eight weeks of intravenous (IV) antibiotic therapy (meropenem and vancomycin) following by eight weeks of oral therapy with clindamycin (600mg q8hours). The symptoms were improved, and the patient discharged. At three and nine months' follow-ups, no significant problem were found.\nOUTPUT:" }, { "from": "agent", "value": "Delayed Infection of Occipitocervical Fixation, Achondroplasia" } ]

[ { "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 8-year-old autistic male presented to the emergency department with severe bilateral leg pain and difficulty walking. Additional recent medical history included gum swelling and bleeding, low-grade fever and a maculopapular rash in bilateral upper and lower extremities. Routine blood work, additional tick titres and autoimmune workup were all normal. A clinical diagnosis was unclear and a whole-body bone scintigraphy examination was ordered followed by subsequent radiographs. Bone scintigraphy demonstrated increased radiotracer activity in bilateral shoulders, wrists, hips, knees and ankles, most severe in the knees (Figure 1). Radiographs of the above-mentioned areas were all normal (Figure 2). Differential considerations included infiltrative processes such as leukaemia, neuroblastoma metastases and multifocal osteomyelitis. Multifocal fractures were felt to be unlikely. Further evaluation with MRI was recommended. Subsequent contrast-enhanced MRI of both femurs demonstrated intense metaphyseal signal abnormality and enhancement in bilateral proximal and distal femurs and proximal tibiae (Figure 3). Subperiosteal signal abnormality and enhancement along the metaphysis of both femurs and tibiae was also observed (Figure 3). MRI findings correlated with findings seen on whole-body bone scintigraphy but were occult on radiographs. An infiltrative process such as leukaemia was of primary concern. Following MRI, a peripheral blood smear and a bone marrow aspiration were obtained to evaluate for haematological malignancy; both were negative. Urine and blood cultures were obtained and both were normal. Perplexed by the abnormal imaging findings and normal laboratory work-up, further discussion with the patient's mother revealed that the patient's diet consisted solely of cookies, brown sugar pop tarts, chocolate milk and Krispy Kreme doughnuts. Nutritional deficiency was considered the cause of the patient's symptoms and a complete vitamin panel was ordered that revealed a low vitamin C level of 0.1 mg dl--1 (normal 0.4-2.0 mg dl-1). All other vitamins were normal. Treatment consisted of corrective nutritional measures and supplemental vitamin C therapy. The patient's symptoms rapidly improved and he was discharged home and instructed to take 100 mg of supplemental vitamin C twice a day. After approximately 8 months of supplemental vitamin C therapy, the patient returned for a follow-up MRI of both femurs. Metaphyseal abnormalities seen on initial MRI had completely resolved on the follow-up MRI examination (Figure 4).\nOUTPUT:" }, { "from": "agent", "value": "Scurvy" } ]

[ { "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 8-year-old boy was diagnosed with nonmetastatic osteosarcoma of the left lower femur. He was treated with neoadjuvant chemotherapy with PAM protocol (cisplatin, doxorubicin, high-dose methotrexate). A reduction of tumor size was noted after presurgery chemotherapy. However, as the tumor was radiologically close to the posterior vessels, he was not considered for limb conservation surgery and underwent transfemoral amputation. Histopathology showed good response to preoperative chemotherapy (more than 90% necrosis). After amputation, the patient was continued on postoperative chemotherapy. He received total cumulative doses of cisplatin (720 mg/m2), doxorubicin (450 mg/m2) and high-dose methotrexate (144 g/m2). After completion of the therapy, he was on regular follow-up every 2 months with blood tests and radiological examination of the local area and chest. Within 8 months of treatment completion, he presented with multiple purpuric spots over the neck and arms. The complete blood count showed a white blood cell count of 45.3x10/l, Hb of 13.2 g/l and platelets 6x10/l, with the peripheral smear showing 41% blasts. Bone marrow examination revealed hypercellularity with marked suppression of normal hematopoiesis and extensive infiltration by blasts (71%). Blasts were large, with moderate to abundant lightly basophilic cytoplasm. Some cells were vacuolated while others contained fine azurophilic granules. Nuclei were round and folded containing, one to three nucleoli [Figure 1]. On cytochemistry, the blasts were nonspecific estrase+++ (fluoride sensitive), Sudan black++, peroxidase+ and periodic acid Schiff stain diffuse weak+. Immunophenotyping analysis of gated cells showed that blasts expressed CD13, CD33, CD14, HLA-DR, CD68 and myeloperoxidase. On karyotyping, 30 metaphases were analyzed, of which 29 showed 46XY and the remaining one showed -5. Applying the 5q31/5p15 probe on bone marrow interphase cells, two chromosomes 5 were detected in 95% of the cells. Because the monosomy of chromosome 5 was detected only in one of the 30 examined metaphases, it was not of clonal origin. Before initiation of the treatment, the patient had severe pulmonary hemorrhage, to which he succumbed.\nOUTPUT:" }, { "from": "agent", "value": "Secondary acute myeloid leukemia" } ]

[ { "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 needed intubation, so he was intubated with a 4.5cc ETT. Intubation was performed in the second attending and with a metal stylet during both attendings. However, we noticed difficulty in removing the stylet. After intubation, the patient maintained his oxygen saturation and had good air entry into both sides of the lungs. Unfortunately, we did not notice that the stylet was slightly short after removal. In the first 6 hours, unexplained short desaturations occurred repeatedly. After intubation, radiography was performed, and it was suspected that there was a remnant in the trachea at the level of the bifurcation. Then we observed an accumulation of CO2 in the VBGs in the first 6 hours. Suction was performed, and we had difficulty aspirating the endotracheal tube. A chest radiograph showed a foreign body (Stylet's part) in the tube and trachea (see Figures 1 and 2). We checked the intubation kits and found that a stylet was booked at the end. The otolaryngology team was called in. The flexible endoscope shows the stylet tip in the trachea. The endotracheal tube was removed, and a rigid bronchoscopy was performed. A stylet was retrieved with telescopic forceps. The patient was easily reintubated after the procedure. After removing that part, the patient's condition improved regarding ventilation with the same oxygenation issue. After removal, there was an immediate improvement in tidal volumes and peak airway pressures.\nOUTPUT:" }, { "from": "agent", "value": "Partial Obstruction of the Endotracheal Tube by a Part of the Metallic Stylet, Respiratory failure due to covid-19, Pneumothorax" } ]

[ { "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 59-year-old woman presented herself with an exophytic mass of 2 cm adherent to the mandible and localized distally of tooth 36. Polymerase chain reaction (Micro-ident, Hain Lifescience GmbH D-72147 Nehren) (PCR) revealed an infection with Porphyromonas gingivalis and Tannerella forsythia (red complex). The expansion of the tumor reached from the sulcus glossoalveolaris with its center along the alveolar crest to the adjacent buccal mucosa (Figure 1). The patient reported herself to be a never smoker and never ingested alcohol. The visit of our department was induced by progressive pain and increasing swelling. The preoperatively taken orthopantomography (OPTG) revealed a considerable generalized horizontal type of bone loss within the upper and the lower jaw, as also a distinct inter- and periradicular osteolytic lesion at the region of 36 (Figure 2). A both-sided selective neck dissection and partial resection of the mandible followed. The clinical appearance (Figure 1) showed an exophytic mass with contact to the distal root of 36. Intriguingly, the OPTG showed no arrosion of the distal mandible but apparently an inhomogeneous radiolucency between the roots of the molar. The cross-section specimen (Figure 3) furthermore highlights the interradicular spreading of the tumor without an infiltration of cancellous bone or the distal alveolar crest. HPV status by p16 immunostaining was negative. Taking all clinical findings together, the present case supports the hypothesis of a possible de novo development of malignancy from the interradicular periodontium.\nOUTPUT:" }, { "from": "agent", "value": "Chronic Periodontitis, Oral 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: In this case series, we report on four teenagers with congenital SFK presenting with menstrual problems due to a Müllerian anomaly. Image Caption and Description: \nImage caption: []\nImage description: []\nCase Report: \nThe third case concerns a girl whose antenatal ultrasound at 20 weeks pregnancy suggested 2 kidneys. However, at the subsequent ultrasound at 32 weeks pregnancy the left kidney was no longer visible. A VCUG and mercaptoacetyltriglycine (MAG3) renography ruled out VUR and ureteropelvic-junction (UPJ) stenosis, respectively. At the age of 11 years, menarche occurred after which menses were sparse, both in frequency and in the amount of blood loss. Because of irregular menses and inconstant vaginal blood loss the gynecologist was consulted. Currently she is 12 years old, has started oral contraceptives and is awaiting surgical correction at the age of 16 years.\nOUTPUT:" }, { "from": "agent", "value": "Uterine Anomalies, Congenital Solitary Functioning Kidney" } ]

[ { "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 female with a history of untreated hypertension presented to the emergency department with severe headache and a decreased level of consciousness. A right frontal EVD was inserted, and the patient underwent suboccipital decompression and clot evacuation, with clinical improvement. Subsequent vascular imaging, including magnetic resonance (MR) and digital subtraction angiography was negative for pathology [Figure 2a-c]. A thorough hematological workup was also negative. Following burr hole placement, the dura was coagulated and monopolar cautery along a forceps was used to puncture the dura and cauterize the pia. After a single pass, good CSF egress was observed, and the ventricular catheter was gently advanced to approximately 10 cm. On day 15 following VP shunt insertion, the patient developed a dilated and fixed right pupil. An EVD was inserted through the previous right frontal burr hole, and a CT angiogram followed by a four-vessel angiogram revealed a pseudoaneurysm of a right distal middle cerebral artery (MCA) branch immediately adjacent to the entry point of the ventricular catheter in the right parietal region [Figure 2d-f]. A right parietal mini-craniotomy was performed for coagulation of the right distal MCA pseudoaneurysm and removal of the VP shunt. Repeat VP shunt placement was performed 2 months following pseudoaneurysm resection. The patient was discharged to a rehabilitation facility and continued to make cognitive and functional improvement. She has since been discharged home with in-home nursing and physiotherapy assistance.\nOUTPUT:" }, { "from": "agent", "value": "Iatrogenic pseudoaneurysms, Hypertensive hemorrhage, Communicating hydrocephalus, Acute intraparenchymal hemorrhage, Acute 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: One large duplication of 4q11-q13.1 was detected in a 12-month-old female with generalized tonic-clonic seizures and growth retardation. A previous study had detected duplication at 4q11-q13.1 in patients with idiopathic short stature, and TMEM165 and POLR2B in this region were suspected as candidate genes for growth retardation. In the duplicated regions, we also considered the REST gene as another candidate disease-causing gene because of its potential to control fundamental transcription patterns that drive circuit excitability, seizures, and epilepsy. However, due to the large size of duplication, it was difficult to determine the disease-causing gene(s), and the duplication was interpreted as VUS. Altogether, the genetic causes (pathogenic or likely pathogenic variants) of EEs were successfully discovered for 34 (46.6%) infants. Twenty-nine (39.7%) infants carried the SNVs/Indels, and five (6.8%) carried CNVs related to the EEs. And the majority of the disease-causing variants were inherited in de novo pattern (25, 71.4%).\nOUTPUT:" }, { "from": "agent", "value": "Epileptic Encephalopathies, Kahriz syndrome, WS, DS, OS, MPEI, 1p36 deletion syndrome, Angelman syndrome, Miller-Dieker 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 67-year-old postmenopausal female with no past medical or family history of cancer presented with a palpable breast mass on examination with no axillary lymphadenopathy. The mammography showed a lobulated 4.7 cm mass in the left breast upper inner quadrant. Tumor was ER positive in 5% of cells, PR was negative, and Her2 was equivocal (score 2+) but FISH negative. Due to weak ER expression, the receptor studies were repeated but results did not change. Patient underwent a left breast partial mastectomy and left axillary sentinel lymph node procedure. Histological features of ILCEM have been previously reviewed in literature. In this case the ILCEM is diagnosed as the pleomorphic subtype showing cytologic cellular features with abundant eosinophilic cytoplasm, signet ring, and plasmacytoid cells (Figure 2(c)). Isolated tumor cells (ITCs) identified on keratin stained section were present in one out of two axillary sentinel lymph nodes. The case was discussed in tumor board and the decision was to proceed with adjuvant chemotherapy followed by radiotherapy and hormonal treatment.\nOUTPUT:" }, { "from": "agent", "value": "Invasive Pleomorphic-Type Lobular Carcinoma of the Breast, Mucinous 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 59-year-old female patient presented with a personal history of non-insulin-treated diabetes mellitus, dyslipidemia, and hypertension, usually medicated with metformin, perindopril, and simvastatin. The patient attended to emergency service (ES) due to epigastric pain and feeling of fullness, for which was submitted to dioctyl sulfosuccinate enema and later discharged. Due to the persistence of the complaints and, now, with progressive tiredness, the patient frequented the ES two days later, where she underwent an abdominal ultrasound, which revealed pericardial effusion. Objectively, on admission, the patient was conscious, oriented, collaborative, eupneic at rest and hemodynamically stable with rhythmic heart tones, no murmurs, decreased vesicular murmur in the right pulmonary base, free and defenceless abdomen, and lower limbs without oedema. The patient displayed on electrocardiogram a sinus rhythm, 90 bpm heart rate, low amplitude QRS complexes, and nonspecific alterations in ventricular repolarization; chest X-ray was performed with increased cardiothoracic index and bilateral pleural effusion, especially at the base of the right hemithorax; echocardiogram was with large pericardial effusion \"swinging heart\" and partial collapse of the right heart chambers. The patient is admitted to the cardiac intensive care unit, in the context of cardiac tamponade. During hospitalization, the patient underwent: pericardiocentesis, with a total drainage of 1250 cc, whose fluid, according to the pathological anatomy, evidenced neoplastic cells. She also underwent a thoracic-abdominal-pelvic computed tomography which revealed bilateral pleural effusion, with adjacent parenchymal atelectasis, slight pericardial effusion (Figure 1), and zones on the left side, with clear pericardial thickening suggestive of pericardial metastasis, after intravenous contrast. Several nodules in all lung lobes were indicative of metastases. During hospitalization, the patient had several periods of paroxysmal atrial fibrillation, despite chemical cardioversion with amiodarone. The patient was discharged with oral anticoagulation and digoxin, as an effective heart rate management agent.\nOUTPUT:" }, { "from": "agent", "value": "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 HUC assigned to the patient's medical ward conveys that surgical management is no longer being considered for the patient, hence palliative care consultation is being solicited to help establish medically reasonable \"goals of care.\" Per the HUC, if further information is desired, the palliative care team should review the electronic medical records (EMRs) or page the hospitalist directly. Upon reviewing the EMRs, the palliative care clinician identifies discussions between the hospitalist and the patient about his global health picture, prognosis, and desire for information on next steps. An attempt is made to reach the hospitalist, but a covering provider returns the page, who does not have further details to offer. Considering institutional consult response standards, the consultant opts to complete the consult sans a direct conversation with the referring provider. When asked to elicit his understanding of illness and care preferences, the patient conveys to the palliative care team his wish to avoid physical suffering and future hospitalizations knowing now that his cancer is not curable. Through the natural course of their conversation with the patient, they recommend home hospice services for his posthospitalization care. When this is reported back to the referring hospitalist, he conveys displeasure that hospice care was discussed, as he hoped the palliative care team would adhere to the consultation question: help with addressing \"goals of care.\" The hospitalist clarified that since the patient was naive to systemic cancer treatments, he was concerned that hospice care discussions would be premature and confuse the patient. By \"goals-of-care discussions,\" he clarifies that he meant eliciting patient care preferences for code status and whether transfer to the intensive care unit should be pursued if the patient became critically ill: \"Since you are the experts in communication, I thought you could do this better than me.\"\nOUTPUT:" }, { "from": "agent", "value": "Malignant bowel obstruction, Widely metastatic colorectal 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: We present a case of an 18-year-old female who was apparently well who presented with multiple episodes of vomiting, upper abdominal pain and constipation 1 year back which was managed conservatively as subacute intestinal obstruction at the local hospital from which she made a full recovery. However, she kept developing three similar episodes over the rest of the year. In-between these episodes, she was completely asymptomatic and did not show symptoms of any food intolerance. In the process of evaluating her symptoms, she was managed at a nutrition clinic and a conservative approach was tried. A psychiatric evaluation was also performed to rule out any psychogenic vomiting. Thus, the cause was isolated to be entirely of organic pathology. She presented to the surgical clinic with the above history, however, she was asymptomatic at that time. She was thinly built with a body mass index (BMI) of 18.4 kg/m2 on presentation. The remaining examination was unrevealing. Her basic biochemical investigations were normal, and initial imaging from ultrasound did not show any abnormalities. Further imaging with a contrast enhanced computed tomography (CECT) showed partial obstruction of distal duodenum at the crossing of SMA due to reduced angulation between SMA and aorta. There is also acute angle in the narrowed point of duodenum at the level of SMA due to duodenal and Jejunal redundancy. There was no associated gut malrotation or any masses or filling defects in stomach or duodenum (Figures 1-3). Patient underwent an elective laparotomy with upper midline incision and duodenojejunostomy was performed as there were no facilities available for a laparoscopic approach. She had an uneventful recovery with good tolerance of oral intake and was discharged on post-operative day 3. Patient was reviewed in the post-operative clinic in 4 weeks and 6 months' time, her symptoms had resolved with a significant rise in BMI to 22.3 kg/m2.\nOUTPUT:" }, { "from": "agent", "value": "Superior mesenteric artery 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: Patient is a 73 year-old right hand dominant female who initially presented to the office complaining of atraumatic right shoulder pain with activity and limited range of motion of longstanding duration. On physical exam, she was found to have significantly limited active range of motion of the right shoulder and clinical signs of impingement. Radiographs at that time demonstrated superior escape of the humeral head with impingement of the greater tuberosity on the acromion and early acetabularization of the acromion (Fig. 1). MRI findings were consistent with her x-ray and also demonstrated a lack of contiguous supraspinatus or infraspinatus tendon. The patient was brought to the operating room and placed in the beach chair position. An incision was made from just lateral to the coracoid to the medial border of the proximal humeral shaft in line with the axillary fold. Subcutaneous tissue was dissected and the cephalic vein was identified. As the cephalic vein was mobilized and the clavipectoral fascia was incised, a discrete, branching, fascicular nerve was identified lateral and deep to the cephalic vein within the deltopectoral groove (Fig. 2). The nerve was further dissected and traced both proximally and distally. Distally, the nerve and all branches were found to be diving into the anterior deltoid muscle. Proximally, it was found to run deep to the conjoined tendon, towards the brachial plexus. The nerve was freed from the deltoid muscle belly, allowing enough excursion to access the glenohumeral joint via a small deltoid window. The remainder of the operation concluded without complication and the wound was closed primarily (Fig. 3). The patient was neurovascularly intact post-operatively with intact sensation in the axillary nerve distribution and able to fire her deltoid muscle. She healed without complications. At 4-month follow-up, she was doing well and able to actively abduct and forward flex her right shoulder to approximately 120 degrees (Fig. 4).\nOUTPUT:" }, { "from": "agent", "value": "Rotator cuff arthropathy" } ]

[ { "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 fifteen-year-old patient was seen in 2001 with primary amenorrhea and normal secondary sexual characteristics. Thelarche and pubarche occurred at 11 years of age. Laboratory tests included follicle-stimulating hormone (FSH), luteinizing hormone (LH), dehydroepiandrosterone sulfate (DHEA-S), prolactin (PRL), and thyroid-stimulating hormone (TSH), and they were all within the normal ranges. Magnetic resonance imaging showed a nonexistent uterus and presence of ovaries bilaterally. In 2002, the patient was submitted to a neovaginoplasty and, in 2003, to a surgical correction of stenosis. She also started using a vaginal mold. The patient remained asymptomatic until 2009 when, with 24 years of age, she appeared with a complaint of abdominal pain. The physical exam was normal and she was then submitted to a pelvic sonography in the beginning of 2010. The exam showed an absent uterus and topic ovaries, with the right one measuring 9,3 cm3 and the left one 12,2 cm3. In the retrovesical topography, in continuation with the left ovary, there was a hiperecogenic image with debris, capsulated, with little vascularization in the Doppler study, which measured 45 mm. In a laparoscopy done in March 2010, two rudimentary uteruses and an endometrioma in the left ovary were observed (Figures 1, and 2). The continuous use of an oral contraceptive was established and the patient became asymptomatic. In 2012, the patient returned with gestational wish. She underwent ovarian stimulation, followed by successful oocyte retrieval, in vitro fertilization, and embryo transferral to a surrogate mother. Pregnancy was achieved in the second embryo transferral, and, in November 2013, the surrogate mother gave birth to a healthy newborn.\nOUTPUT:" }, { "from": "agent", "value": "Endometriosis, Mayer-Rokitansky-Küster-Hauser 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 52 year-old man without significant previous medical problems presented to the emergency department with epigastric pain and anorexia for a week. Physical examination revealed normal vital signs but tenderness in the right upper quadrant of the abdomen. He had leukocytosis with a left shift. A plain abdominal radiograph revealed a gas-forming lesion with perilesional air trapping (Fig. 1, arrow) in the right upper quadrant. Abdominal computed tomography showed an enlarged gall bladder with intraluminal (Fig. 2, letter a) and intramural air (Fig. He received an emergency cholecystectomy and a gangrenous gallbladder was removed. The patient received a complete course of postoperative broadspectrum antibiotic therapy and was discharged 2 weeks after admission. Due to the high mortality rate, prompt diagnosis and intervention are imperative. Radiography, ultrasonography, and computed tomography of the abdomen can provide much information for early diagnosis of this disease. Temporary percutaneous cholecystotomy can be another choice in a few select patients. Concurrent broadspectrum antibiotic therapy is also necessary.\nOUTPUT:" }, { "from": "agent", "value": "Emphysematous cholecystitis, 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: Postnatal radiography confirmed a double-bubble in the upper abdomen (Fig. 2). No other associated anomalies were detected, and the nasogastric output was clear and nonbilious. The child was scheduled for laparoscopic duodenoduodenostomy on the second day of life. During surgery, 3 mm trocars were placed in the navel, as well as the left upper and right lower quadrants. The distended proximal duodenum was immediately visible. Therefore, distal duodenum and a portion of jejunum was mobilized and brought close to the proximal portion using transabdominal percutaneous stitches. With both portions of the bowel apposed, enterotomies were performed using cold endoscopic scissors at the anterior aspect (Fig. 3). A 5.8 mm diameter articulating endostapler (MicroCutter 5/80, Dextera Surgical Inc., Redwood City, CA) was introduced through an additional skin incision in the right upper quadrant in trajectory of the aligned portions of duodenum (Fig. 4). Care was taken not to include the papilla in the anastomosis by gently pushing the stapler inferiorly, away from the liver. The combined enterotomy was closed using a running 4-0 Glycolactate suture. Total operative time was 75 min. The staple line was well visible on a postoperative radiograph (Fig. 5). Breastmilk was given on postop day one and the patient was discharged home on postop day 5. At a recent 5 months follow up visit, she was developing and thriving normally.\nOUTPUT:" }, { "from": "agent", "value": "Duodenal atresia, Annular pancreas" } ]

[ { "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: Written, informed consent was obtained from the patient for publication of the report and any accompanying images. A 47-year-old man was admitted to the Unit of Diagnostic Imaging Universita Campus Bio-Medico di Roma for a brain magnetic resonance imaging examination. He was referred to our hospital because of narrowing of the left eyelid. The disorder was associated with occasional nuanced blurred vision. At the level of the left orbit roof in the frontal bone, in-depth thin-film sequences showed a solid lesion likely to be extraconal bone departure, with expansive growth characteristics (diameters of 23 x 15 x 25 mm). This was characterized by intermediate signal intensity on T1- and T2-weighted images, evidence of contrast enhancement and intra-orbital development at the upper-outer quadrant level. The deforming upper-side of the eyeball incorporated the lacrimal gland with no safe cleavage planes from the upper rectus, lateral rectus and the upper eyelid muscle. They were completely incorporated into the lesion (Figure 1). Total body computed tomography (CT) showed numerous secondary mediastinal lymphadenopathy that were bilateral hilars (diameters right 13 x 23 mm and left 36 x 23 mm) or subcarinal (diameters 39 x 25 mm). At the upper pole of the left kidney was a partially exophytic lesion (diameters 72 x 56 x 70 mm), which marked the upper caliceal group, with contextual necrotic phenomena (Figure 2). Locoregional lumbar-aortic lymphadenopathy with a maximum diameter of 20 mm, two repetitive lesions at the body (diameter 21 mm) (Figure 2A and B) and medial arm (diameter 10 mm) of the left adrenal gland, and nodulation of 8 mm in diameter in the right adrenal gland were also seen. In addition, multiple bone lesions in skeletal segments were examined. After CT staging, the patient was subjected to endoscopic ultrasound, and multiple specimens at lymph-node stations 7 and 11L were collected for cytology. As a result of cytological sampling, the patient was diagnosed with RCC. The patient was subsequently followed up in another hospital for management.\nOUTPUT:" }, { "from": "agent", "value": "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: She had a history of irregular menstrual cycles for a year followed by secondary amenorrhea for 6 months duration and intermittent headache and a one-month history of blurry vision. This is similar to the above two cases, which we believe is also thyrotroph hyperplasia as evidenced by the typical \"Dome sign\" and homogenous symmetric architecture. Visual field on perimetry testing was marred by poor comprehension of the patient. Her sodium was 154 mmol/L. On evaluation of the pre-operative hormonal profile it was found that she had a TSH of >100 micro IU/ml. She was started on a dose of levothyroxine 100 microg post-operatively. The young female fortunately did not have any Post-operative Neuro-hormonal deficits and her regular cycles resumed from the third month post-operative. Post-operative hormonal evaluation performed at 6 weeks revealed a free T4 level of 13.8 pmol/L, 8 am S. cortisol of 9.8 microg/dl, FSH- 5.38 mIU/ml, LH-6.4 mIU/ml and IGF-1 - 213 ng/ml which was normal for her age.\nOUTPUT:" }, { "from": "agent", "value": "Primary Hypothyroidism, Pituitary Macroadenoma, Diabetes Insipidus" } ]

[ { "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: During a medical examination, a 30-year-old woman was diagnosed to have BrS on ECG in which the right precordial leads indicated an obvious coved-type ST segment elevation (Fig. 1A and B). The patient was referred to our hospital for evaluation and treatment. At the initial examination, she reported no previous episodes of palpitations, faintness, or syncope, and the physical examination showed no abnormalities. However, she had a strong family history of sudden cardiac death; her father had symptomatic BrS and had undergone ICD placement for secondary prevention. Signal-averaged ECG gave positive findings in both atria and both ventricles (Fig. 1C and D). Despite ECG findings indicative of BrS, she had no symptoms; therefore, she was carefully observed at the outpatient clinic of our hospital. 2A). 2B). After ICD implantation, the patient's symptoms, such as dizziness, were successfully relieved, and no problems were reported during the 18-month follow-up. She completed two pregnancies during the follow-up period, with no symptomatic changes occurred during that time. Furthermore, the ST segment elevations in the right precordial leads were attenuated during the second and third trimesters of pregnancy, in comparison to the periods when she was not pregnant (Fig. 3).\nOUTPUT:" }, { "from": "agent", "value": "Brugada Syndrome, Sinus node dysfunction" } ]

[ { "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 13-month-old boy presented with 3 months of intermittent activity-induced stridor. The patient was born term by normal vaginal birth with no perinatal complications. He had normal acquisition of developmental milestones and did not have any significant prior medical history or contributory family history. One week prior to presentation, he developed upper respiratory tract symptoms, persistent stridor, respiratory distress, easy fatigability with short bursts of activity, dysphagia, and weak cry. He was initially evaluated in an ambulatory clinic for stridor, and subsequently admitted to the pediatric intensive care unit for further evaluation and management. His neurologic examination was notable for normal cognition, bilateral eyelid ptosis worse on the left, mild facial weakness, axial hypotonia and mild proximal weakness of the lower extremities with intact deep tendon reflexes. A neurogenic or myopathic process could not be excluded. Initial diagnostic evaluation noted mildly elevated inflammatory markers with otherwise normal complete blood count, chemistry panel, thyroid studies, and creatine kinase. A nasopharyngeal viral respiratory PCR was positive for coronavirus (non SARS-CoV2). Direct laryngoscopy and bronchoscopy showed bilateral vocal cord immobility with cords in the paramedian position. Magnetic Resonance Imaging (MRI) of the brain and chest were normal. Due to the concern for a myasthenic crisis with worsening respiratory symptoms, he was empirically treated with 5 days of intravenous immunoglobulin (IVIG) followed by prednisone and azathioprine, a steroid-sparing immunomodulating agent. He had mild improvement in symptoms initially, but this was short lived. A second course of IVIG with a trial of pyridostigmine did not result in any clear clinical improvement. Repeat flexible laryngoscopy 2 weeks into treatment demonstrated persistent immobile vocal folds. During this time, the patient developed worsening stridor and respiratory distress requiring tracheostomy.\nOUTPUT:" }, { "from": "agent", "value": "autoimmune myasthenia gravis" } ]

[ { "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 40-year-old female who had conceived following in vitro fertilization presented to an antenatal clinic in the 6th week of gestation complaining of acute lower abdominal pain. At the same clinic, she had received in vitro fertilization treatment with a long gonadotropin-releasing hormone agonist protocol to induce ovarian stimulation for unexplained secondary infertility. She was referred to our hospital due to severe and persistent lower abdominal pain. Her medical history was unremarkable. Her physical examination revealed right lower abdominal tenderness without muscle guarding. Transvaginal ultrasound examination revealed a viable singleton intrauterine pregnancy. Doppler ultrasonography revealed normal ovarian blood flow (Fig. 1A-C). Approximately 14 h after the onset of her acute abdominal symptoms, explorative laparoscopy was performed. The uterus appeared normal in size and shape (Fig. 2A). 2B). The ischemic bluish color of the ovary improved quickly (Fig. 3A-D). Because the congestive ovarian tissue was fragile and easy to tear, we did not perform oophoropexy in this case. The patient's intra-abdominal pressure was 10 mmHg. The operative blood loss was small, and the operative time was 46 min. There were no intraoperative complications, and postoperative follow-up was uneventful. She successfully delivered a healthy infant at 38 weeks' gestation. Follow-up ultrasound showed a normally functioning ovary. The patient's consent was obtained to report this case, and the report was exempted from ethical approval by our institution.\nOUTPUT:" }, { "from": "agent", "value": "Ovarian Hyperstimulation Syndrome, Torsion of the enlarged right ovary" } ]

[ { "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 84-year-old male with a past medical history of hypertension and diabetes mellitus presented to the hospital with progressive dyspnea, altered mental status and hematuria. The patient did not have any fevers, chills, cough, night sweats or weight loss. He denied having any chest pain or abdominal pain. On examination, his blood pressure was 84/46 mmHg, pulse 62 beats per minute, respiratory rate 22 breaths per minute and he had an elevated jugular venous pressure. Bilateral pitting pedal edema extending up to the thighs was prominent and his liver was enlarged. Breath sounds were decreased in bilateral lung bases whereas heart sounds were normal. He was aphasic and unable to move his right lower and left upper extremities on command. On admission, pertinent laboratory findings revealed a hemoglobin of 7.8 g/dl, hematocrit 24.1%, urea nitrogen 115 mg/dl, creatinine 1.7 mg/dl, phosphorus 6.3 mg/dl and an estimated glomerular filtration rate(eGFR) 38 ml/min/1.73m2. A urine analysis demonstrated proteinuria 3+ and hemoglobinuria 3+. His brain natriuretic peptide (BNP) and troponin levels were elevated, 280 pg/ml and I 0.07 ng/ml, respectively. A bedside ultrasound was performed to establish the cause of hypotension and dyspnea. Point of care (POC) ultrasound (POCUS) showed bi-atrial enlargement with a preserved left ventricular function, dilated right ventricle and a plethoric inferior vena cava without respiratory phasic variability. 1, Fig. 2). A non-contrast computed tomography scan of the head was conducted to evaluate altered mental status and weakness which demonstrated multiple cerebral and cerebellar strokes.\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 C was also a 10-year-old girl, who was otherwise healthy other than exhibiting poor growth. At baseline, she was involved in gymnastics; however, this changed when she started to experience right hip pain. This pain persisted at all times of day and was partially relieved by ibuprofen. It was never in the left hip or knees, but she reported some discomfort in her ankles. She had no fevers but developed a transient pustular rash on her palms and soles. As the pain became increasingly disabling, she developed a limp. She was referred to orthopedics, who prescribed crutches and obtained a hip MRI. This showed a lesion in the right medial proximal femur (Figure 3). A bone scan was then performed to look for additional lesions, but none were found. Biopsy of the lesion was consistent with osteomyelitis but was undifferentiated between an infectious vs. inflammatory cause. Our rheumatology team came to the same conclusion (1-year after symptom onset). When we saw the patient, she was tired and pale appearing, with thinning hair. Her BMI percentile was 1%. Musculoskeletal examination was notable for tenderness in the sacroiliac region and right femur, as well as reduced range of motion of her ankles. There were no skin lesions at the time of our exam. WBMRI showed lesions in her proximal right humerus, proximal right femur, bilateral proximal tibias, and bilateral distal femurs. She was treated with indomethacin and has since clinically improved. Given her history of poor growth, a fecal calprotectin was performed to screen for IBD and was positive.\nOUTPUT:" }, { "from": "agent", "value": "Chronic Multifocal Recurrent Osteomyelitis, 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: A 25 year old patient with no medical history showed a 5 cm basicervical anterior swelling, lateralized in the right, which appeared 4 months earlier. The swelling was associated to a mild dysphagia, without evident weight loss or infectious signs. Cervical ultrasound revealed a hypertrophy of the right thyroid lobe, with a 4 cm nodular cyst of the apex and a 1.5 nodule of the base. Biology was normal with no inflammatory signs. Thyroid function tests were normal. The patient was admitted in the ENT unit for right lobectomy. Scintigraphy and fine needle aspiration cytology (FNAC) were not performed before surgery. At the opening of the center line of the neck, we were surprised to find caseum coming from the thyroid with a necrotic destruction of the right lobe (Figure 1), frozen section was not at disposal. The right Loboisthmectomy and dissection of the recurrent nerve were very difficult. HIV serology was negative and general check-up looking for other locations of tuberculosis revealed no abnormalities (Chest X ray, sputum analysis, abdominal ultrasound). A new surgery was performed afterward for left lobectomy. The patient received a six-month antituberculosis regimen: 2RHZE/4RH (R:Rifampicin 10 mg/ kg/ j, H:Isoniazid 5 mg/ kg/ j, Z:Pyrazinamid 20-30 mg/ kg/j), with a satisfying uneventful evolution. No complementary anticancer treatment was necessary.\nOUTPUT:" }, { "from": "agent", "value": "Tuberculous thyroiditis, Papillary carcinoma of the thyroid" } ]