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hippocrates

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Multicare_common_train

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[ { "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 Caucasian man with recently diagnosed eosinophilic chronic myelomonocytic leukemia presented with fevers and right-sided heart failure that failed to respond to diuretics. He denied any history of travel to the tropics. Exam was remarkable for pallor, edema and S4 gallop. He had leukocytosis (54 x 109/L; 55% eosinophilic predominance), anemia and thrombocytopenia (3 x 109/L). Echocardiogram showed grade 2 diastolic dysfunction, moderate mitral regurgitation and elevated right heart pressure. There was apical left ventricular thickening concerning for tumor, laminated thrombus or focal hypertrophy (Figure 1, Movie 1). Given severe thrombocytopenia, endomyocardial biopsy and anticoagulation were contraindicated. Cardiovascular magnetic resonance (CMR, Figure 2, Movie 2, 3) showed increased focal apical wall thickness of 22 mm with hypokinesis of this segment (Figure 2A). First pass perfusion revealed hypoperfused apical and lateral endocardium with a layer of superimposed clot (Figure 2B). Late gadolinium enhancement images showed hyperintense apical fibrosis extending from the endocardium to mid myocardium, covered by a cap where laminated clot was present producing a \"double V\" sign (Figure 2C). This was also confirmed on the 3-chamber early gadolinium enhancement image with long TI of 600 ms that showed apical thrombus distinct from the underlying myocardium (Figure 2D). Early manifestations include symptoms of fevers, dyspnea and swelling. During this phase, infiltration of myocardium and release of eosinophilic major basic protein and reactive oxygen species promote endothelial and myocyte injury. The later stages are marked by myocardial fibrosis and thrombus formation causing a restrictive cardiomyopathy. Our patient was started on imatinib and steroids and his symptoms improved over 2 weeks. Unfortunately, he died from bacterial sepsis after that.\nOUTPUT:" }, { "from": "agent", "value": "Loeffler Endocarditis" } ]

[ { "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 has no history of fever or cough, but he has a history of general weakness for one week prior to the current event. On admission, vital signs were remarkable for a blood pressure of 89/56 mmHg, heart rate of 30 bpm, and oxygen saturation at 90% on room air, which improved to 97% with a nonrebreather mask. Initial ECG demonstrated sinus bradycardia with third-degree AV block and ST-segment elevation in inferior leads (Figure 1(c)). A transcutaneous temporary pacemaker wire was inserted. Chest radiography (CXR) demonstrated bilateral pulmonary congestion with infiltration in the left midlung zone.\nOUTPUT:" }, { "from": "agent", "value": "Inferior ST-Elevation Myocardial Infarction, Atrioventricular Conduction Disorders, COVID-19 Infection, SARS-CoV-2 pneumonia, acute respiratory failure, disseminated intravascular coagulation, severe sepsis, septic shock, 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: A 3-year-old boy, with no significant past medical history, initially presented with a \"pinkish\" lesion on his abdomen that was first thought to be a \"bug bite.\" When the spot did not resolve after six weeks, he was referred to a dermatologist who performed an excisional biopsy. He had no evidence of lymphadenopathy in any of his nodal basins on physical exam. Further molecular and immunohistochemical workup demonstrated positivity for ALK (2p23) rearrangement as well as CD30+ cells. He was referred to pediatric surgery at this point for wide local excision of the previous biopsy site. In addition, it was proposed to also perform an SLNB. Lymphoscintigraphy, done preoperatively, using technetium 99 was performed and showed the draining nodes in his right axilla (see Figure 1). Lympozurin blue was injected around the previous biopsy site, and exploration of the right axilla revealed two sentinel nodes with greater than 4 times the background radiation that were blue. These were excised (see Figure 2). He also underwent bone marrow biopsy, which demonstrated no lymphoma population by histological examination, immunohistochemical staining or FISH cytogenetics. He was placed on POG 9219 receiving a combination of cyclophosphamide, vincristine, doxorubicin, and steroids over the next three months. He is now 8 months after completing all of his therapy and is without evidence of recurrent disease.\nOUTPUT:" }, { "from": "agent", "value": "Radiographically negative, asymptomatic, sentinel lymph node positive cutaneous T-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: We present here three cases of FES in SCD. All three patients provided their written consent. He was admitted with lower limb pain of extreme and unusual severity and was treated with parenteral opiate analgesia and fluids. There were no obvious precipitating factors for his crisis, and he only gave a history of a \"flu-like\" illness while visiting Amsterdam 2 weeks before this presentation. His vital signs at presentation were stable, and his baseline hematological and biochemical investigations are summarized in Table 1. However, within the first 48 h of presentation, he deteriorated rapidly developing respiratory failure and bilateral pulmonary infiltrates on the chest radiograph. He was commenced on broad spectrum antibacterials, and an emergency manual partial exchange transfusion was undertaken achieving a posttransfusion HbS level of 34%. A few hours later, he became suddenly comatose and required intubation. An urgent CT head was reported as normal. Antivirals were added to his treatment, and he was further exchanged to an HbS of 22%. In the following 72 h, he developed progressive pancytopenia with a leukoerythroblastic picture on the peripheral blood smear and a striking number of circulating nucleated red cells. No bacteria or viruses were detected in his blood, or cerebrospinal fluid except for HPVB19 that was detected by serology (IgM+/IgG-) and polymerase chain reaction (PCR). An MRI brain showed multiple widespread microhemorrhages consistent with cerebral fat emboli (Fig. 1), and based on the clinical, hematological, and radiological features, a unifying diagnosis of FES was made. He remained in ICU with reduced Glasgow coma scale for a month, but then started making a gradual but slow neurological recovery. He was discharged after prolonged in-patient neuro-rehabilitation, 1 year after the original admission, substantially improved, independently mobile but with some residual cognitive impairment. He was initially treated with regular automated red cell exchange transfusion (ARCET) for a year (until he declined it) but continues to take hydroxycarbamide.\nOUTPUT:" }, { "from": "agent", "value": "Sickle-cell disease, Fat embolism syndrome, Avascular necrosis, Acute chest 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 AM is a Caucasian female born at a community hospital by cesarean section to a 20-year-old gravida 1 para 0 mother of Western European descent. The mother had regular prenatal care, took prenatal vitamins and did not use alcohol, tobacco, or illicit drugs during the pregnancy. During prenatal visits, the fetus had reassuring vitals so an ultrasound was not obtained. The pregnancy was complicated by gestational diabetes and preeclampsia for which the mother had been placed on bedrest during the final trimester. At 42 weeks gestation, the mother was induced, but during labor, fetal distress was noted, requiring an emergency cesarean section to be performed. Birth weight was 7 lbs 4 oz. (3.29 kg) and length was 17'' (43.18 cm). After birth, our patient failed to spontaneously void and concern for acute renal failure resulted in her being transferred to a tertiary pediatric hospital for further evaluation. This later resolved during the hospitalization. During the admission, radiographs of the chest, abdomen, and pelvis were obtained. The images demonstrated multiple vertebral segmentation defects in the thoracolumbar spine and agenesis of the distal sacrum and coccyx. She was referred to pediatric orthopaedics. Since our patient was healthy and without other congenital anomalies, she was conservatively followed with serial radiographic evaluations every 6 months (Figure 1). On exam, she was noted to have a short neck with limited range of motion. Bowel and bladder function were normal. Motor responses were good, and there was full strength in the lower extremities.\nOUTPUT:" }, { "from": "agent", "value": "Spondylocostal Dysostosis, Klippel-Feil deformity" } ]

[ { "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 75-year-old woman was admitted to the Emergency Department due to abdominal pain associated to a pre-syncopal condition. Twelve hours earlier, she had performed a complete colonoscopy as a post-polypectomy surveillance at another hospital. The patient reported an open-cholecystectomy, denied any kind of trauma in the previous days and mentioned that she was suffering from Hashimoto's thyroiditis and arterial hypertension, for which she was regularly in treatment with levothyroxine sodium and calcium channel blocker. No anticoagulant/antiplatelet agents were taken. On admission, the oral temperature was 38.6 C, blood pressure 105/55 mmHg, pulse rate was 98/minute and the respiratory rate 17/minute. Increases in white blood cell count (16.4/mm3; neutrophils 85.1%) and plasma D-Dimer 359 (NR: 2-200 ng/ml) associated with anemia (hemoglobin 10.7 g/dl) were present. Renal, bilio-hepatic, and pancreatic functions were normal. Physical examination revealed signs of peritoneal reaction to palpation. At this point, it was decided to perform an abdominal focused assessment with sonography (FAST), which demonstrated a hemoperitoneum. The patient underwent an emergency laparotomy with splenectomy, recovered well, and was discharged ten days later in good condition.\nOUTPUT:" }, { "from": "agent", "value": "Splenic Hematoma, Grade IV splenic rupture" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: The patient was a 37-year-old Japanese man without a significant medical history. Two weeks prior to admission, he had returned to Japan from Nigeria after a 6-month business visit. He had taken no chemoprophylaxis for malaria. He had not used any repellent and was sometimes bitten by mosquitoes. Six days prior to admission, he experienced general malaise, fever, and headache. Five days prior to admission, he visited a clinic nearby and was diagnosed with common cold. Loxoprofen and cefaclor were prescribed. Three days prior to admission, he visited another clinic and was again diagnosed with common cold. His symptoms had not improved, and his mental state appeared altered. He was transferred to the Japanese Red Cross Narita Hospital by ambulance. On admission, his mental status was E4V4M6. His vital signs were as follows: blood pressure of 138/87 mm Hg, heart rate of 126 beats/min, body temperature of 38.5 C, respiratory rate of 28 breaths/min, and oxygen saturation on room air of 98%. His physical examination results revealed slight jaundice on the conjunctiva. Laboratory test results revealed anemia with a hemoglobin level of 12.5 g/dL, thrombocytopenia with a platelet count of 17 000 /muL, high bilirubinemia with a total bilirubin level of 5.1 mg/dL, and elevated inflammatory markers, with elevated C-reactive protein levels of 23.14 mg/dL. The examination of his peripheral blood smear showed P. falciparum-infected erythrocytes with a parasitemia index of 5.4% (Figure 1). P. falciparum infection was later confirmed by performing polymerase chain reaction. We administered intravenous quinine. After an initial increase in his parasitemia index to 8.6%, it decreased to <0.1% on hospital day 3. Intravenous quinine was replaced with artemether/lumefantrine and was continued for 3 days. He recovered fully and was discharged on hospital day 10.\nOUTPUT:" }, { "from": "agent", "value": "Plasmodium falciparum malaria" } ]

[ { "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 tumor infiltrated the celiac artery (CA) without involvement of GDA (Fig. 1a, b). CT also confirmed the presence of r-RHA (Fig. 1c). The portal vein and superior mesenteric vein were free from the tumor invasion. There were no enlarged lymph nodes or any metastatic lesions. At laparotomy, inconsistent with the evaluation of preoperative imaging, the tumor was found to involve the confluence of GDA and PHA. After clamp for PHA, doppler ultrasonography confirmed arterial flow in the liver. Therefore, PHA and GDA were ligated and the pancreas was divided with a surgical stapling device (ECHELON 60 mm, Gold cartridge) along with the right edge of the portal vein. Finally, we cut the left gastric artery (LGA) and CA, and finished Ex- DP-CAR (Fig. 2). The postoperative course was uneventful, with no ischemic complications, and the patient was discharged 10 days after the surgery (Fig. 3). The surgical margin was negative for cancer cells. There was no evidence of lymph node involvement and the pathological stage was IIA according to the UICC 8th classification. Postoperative chemotherapy with S-1 (120 mg/body) was carried out for 6 months and the patient remains well with no evidence of recurrence nor ischemic complication such as liver abscess and gastric ischemia at 18 months after the surgery.\nOUTPUT:" }, { "from": "agent", "value": "Pancreatic body cancer, Moderately differentiated invasive ductal adenocarcinoma of the 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: His initial cardiac magnetic resonance at age 22 demonstrated severe asymmetric septal hypertrophy (Fig 1a and b), near-obliteration of the mid-left ventricle in systole, and systolic anterior motion of the mitral valve. There was hyperdynamic global left ventricular systolic function, in agreement with previous echocardiograms. On post-contrast imaging (Fig 1c), diffuse sub-epicardial late gadolinium enhancement in the left ventricular free wall (green arrows) and multiple focal septal areas of mid-myocardial late gadolinium enhancement (red arrows) were seen. Subsequent cardiac magnetic resonance studies have demonstrated progressive late gadolinium enhancement. His latest cardiac magnetic resonance study at age 27 (Fig 1d) demonstrates sub-epicardial partial thickness late gadolinium enhancement in large areas of the anterior, lateral, and inferior left ventricular free wall segments (green arrows) and mid-myocardial late gadolinium enhancement in the anterior and inferior ventricular septum starting at the level of the papillary muscles and extending to the apex (red arrows). The patient has continued to exhibit preserved, hyperdynamic left ventricular systolic function (Supplemental Movie 1).\nOUTPUT:" }, { "from": "agent", "value": "Duchenne muscular dystrophy, Hypertrophic cardiomyopathy" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: White female patient; nine years and nine months old. She had been overweight since the age of six, and her mother noticed a decrease in growth one year before the consultation. She also exhibited depression and anxiety. She used prednisone until she was seven years old because of bronchial asthma. Height 1.34 m, Z score -0.49 (=P31); weight 59 kg, Z score 3.18 (>P97); BMI 32.9 kg/m2, Z score 3.54 (=P99); Moon facies, Tanner development stage of M2 P3, generalized obesity with fat deposition in supraclavicular fossa, cervical acanthosis nigricans, fine axillary hairs, thin purplish stretch marks in abdomen and breasts. Bone age of a nine or ten-year-old, with a chronological age of nine years and six months old. ACTH-dependent hypercortisolism was confirmed (Table 3). The 1.5T MRI with a dynamic study did not demonstrate the presence of adenoma at the age of 9 years and 10 months, but in the 3T MRI with a dynamic study performed at age 10 years and 3 months, the sagittal cut in the T1 TSE sequence after the administration of (gadolinium) contrast, demonstrated the contrast-enhanced, oval-shaped image of the anterior adiphyophysis measuring 3 x 2.3 x 2.1 mm. Details of the examination technique are described in Table 3. The patient underwent transsphenoidal surgery at ten years of age. She continued to grow with transient diabetes insidious and central permanent hypothyroidism. She presented insufficient adrenal in the postoperative period, which is compatible with the cure for hypercortisolism. She used prednisone for two years. She showed progressive weight loss. Her final height was 1.51 m, with a family target of 1.59 m. She presented new weight gain without the recurrence of hypercortisolism.\nOUTPUT:" }, { "from": "agent", "value": "Cushing'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: Patient D is status-post bilateral acoustic tumor resection, presenting with progressive visual loss in the right eye secondary to an enlarging tumor of the orbital apex (Figure 2). The patient previously underwent surgery in 2004 and 2006 on the right and left sides for acoustic tumor removal, respectively, and placement of an auditory brainstem implant. In 2008, the patient's vision on the right began to decline, and the recommendation was made for optic nerve decompression with possible resection of tumor, followed by Gamma Knife radiosurgery in the event the tumor could not be resected. Intra-operatively the tumor was found to be densely adherent to the soft tissues on the orbit without a distinct plane between the tumor and optic nerve dura. It was felt that resection would not be possible without further visual compromise. Decompression was then followed by gamma knife radiosurgery; the tumor volume was 1.7 cm3, treated to 12Gy at the 50% isodose line. The treatment plan consisted of a total of 17 shots, all with 4 mm collimator. Peak dose to the optic nerve was 10.4 Gy, with 92% of the optic nerve volume at or below 8Gy. Pre-operative visual acuity was found to be 20/200. Her vision improved within a year post-operatively to 20/70, and has remained stable at last follow-up (60 months).\nOUTPUT:" }, { "from": "agent", "value": "Intra-Orbital Meningioma, Neurofibromatosis Type 2, Hyperplastic Persistent Primary Vitreous" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 23-year-old sexually active female presented to the emergency department of our hospital complaining of left wrist pain and two small pustular lesions on palm of the left hand. The pain was associated with movements of hand. She denied history of drainage from pustules and fever. The review of systems was otherwise unremarkable. The initial vitals revealed heart rate of 126 bpm, temperature of 99.1 F, respiratory rate of 18/min, and blood pressure of 130/76 mmHg. On physical examination, the left wrist was tender on palpation while the hand movements were limited especially upon extension. There were two small pustular lesions one on the palm and the other on the left thenar eminence with minimal erythema but no active drainage. The laboratory data revealed total white count of 24,900/microl (normal 4,500-1,000/microl). X-ray of left hand and wrist revealed no abnormalities. Wound culture was taken from one of the skin lesions. Her pain continued to worsen despite antibiotic and she came back to the emergency department. A CT scan of the left hand revealed findings suggestive of tenosynovitis in the fourth extensor compartment but no abscess or septic arthritis. Due to her prior history of allergy to vancomycin, she was started on intravenous (IV) daptomycin and clindamycin. Her wound culture sent previously came back positive for Neisseria gonorrhoeae. Urine test was negative for gonococcus but positive for chlamydia. Blood cultures came back negative. Erythrocyte Sedimentation Rate (ESR) and C Reactive Protein (CRP) were within normal limits. The edema and limitation of range of motion of the left hand persisted despite appropriate antibiotic therapy; hence, she underwent radical tenosynovectomy of the extensor compartment of the left wrist with resolution of her symptoms. She was discharged home on IV ceftriaxone with follow-up in the infectious disease clinic. The duration of IV antibiotic treatment would be determined per her clinical improvement on subsequent follow-up.\nOUTPUT:" }, { "from": "agent", "value": "Disseminated gonococcal infection, Chlamydial infection" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 48-year-old white man with abdominal pain and fever (above 39 C) came to our Emergency Ward. The patient was in a status of good health since three weeks before admission, when he was affected by postprandial vomiting and epigastric pain. On examination he showed a splitting of the first heart sound and a liver two fingers beneath the right costal margin; the rest of examination was normal. Laboratory tests revealed normal value of blood count, except eosinophilia (1305 cells/mm3 that is about 11,3% of the white blood cells); hepatic parameters, glycemia, and renal function were also in range. Patient's past medical history was unremarkable: he had only undergone an appendicectomy several years before. Patient underwent ultrasonography of the abdomen that revealed a septated cystic lesion with \"honeycomb-like\" structures localized in the hepatic left lobe (Figure 1). Wide parenchymal lesion caused constriction and dislocation of suprahepatic veins and left branch of portal vein. Given the mass features a provisional diagnosis of hydatid cyst was made, supported also by presence of echinococcal antibodies detected by indirect hemagglutination and by patient history (he referred that he was a woodcutter). The patient underwent a surgical approach with a radical procedure of cysto-pericystectomy. On the 8th postoperative day, patient had referred intensive epigastric pain radiating to right shoulder and jaundice (conjugated bilirubin 4.2 mg/dL) with severe anaemia (that necessitated blood transfusions) and black stool. A computed tomography study of the abdomen revealed a mild bile duct dilatation and an inhomogeneous collection with air bubbles in the area where previous surgical treatment was made (Figure 2). Since computed tomography findings were inconclusive, MRCP was performed. On magnetic resonance images there was material into bile ducts with mixed signal intensity on T2-weighted images according to the presence of blood products in various stages of breakdown (Figure 3). On MRCP 3D images some filling defects could be detected. Our patient underwent a therapeutic endoscopic retrograde cholangiopancreatography procedure that confirmed hepatobiliary tract dilatation because of obstruction by blood clots (Figure 4).\nOUTPUT:" }, { "from": "agent", "value": "Haemobilia, 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: On admission to the hospital, the patient's left eye had an IOP of 6 mm Hg without any topical or systemic IOP-lowering medication. Approximately 6 h after an uneventful DMEK procedure - performed by an experienced surgeon (C.C.) in a standardized fashion - IOP was 32 mm Hg in the left eye. The patient was given 250 mg of acetazolamide systemically to lower aqueous humor production. Two hours later, IOP had increased to 42 mm Hg. Slit-lamp examination showed a deep anterior chamber with no sign of pupillary block and a functional inferior iridotomy. Bubbles of SF6 were present inside the trabeculectomy bleb. Cautious anterior chamber paracentesis was performed to lower the IOP to 10 mm Hg. The remaining volume of SF6 was at 50%. In the following days, the patient was given 250 mg acetazolamide t.i.d. and potassium substitution as well as pilocarpine 2% t.i.d. as part of the postoperative standard medication after DMEK. With this treatment, no further IOP peak could be observed. In every slit-lamp examination up to day 4 after DMEK, gas filling of the bleb was observed (Fig. 2). On postoperative day 6, a rebubbling procedure was recommended because of focal graft detachment. Eight days after surgery, the patient could be discharged from the hospital to ambulatory care. On the last day of hospitalization, IOP was 10 mm Hg and BCVA was 0.8 logMAR in the left eye. The cornea was clear with a well-attached corneal graft, a remaining SF6 volume of 40%, and gas filling inside the bleb of approximately 80%.\nOUTPUT:" }, { "from": "agent", "value": "Fuchs endothelial dystrophy, Secondary open-angle glaucoma due to pseudoexfoliation 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 89-year-old female patient with a history of acute myocardial infarction, stroke with motor sequelae, pacemaker carrier due to a second-degree atrioventricular block (Mobitz type II) and severe aortic valve disease was admitted to the 1st time to our emergency department (ED) due to acute prostration and confusion. At that time, a plasma glucose level of 50 mg/dL was detected with prompt relief of symptoms after the administration of endovenous glucose. The patient was discharged with recommendation to monitor capillary blood glucose and restrict rapidly absorbing carbohydrates of her diet. Ten-days later, she was re-admitted to our ED complaining of recurrent hypoglycaemia, especially during fasting, with the lowest capillary glucose level detected at home of 30 mg/dL. The patient reported no weight gain, no history of diabetes and no evidence of use or access to hypoglycaemic drugs at home. At the first episode, blood samples were collected to evaluate plasma levels of glucose, insulin and c-peptide: a low glucose value (45 mg/dL) with inappropriately elevated insulin (12 microIU/L) and c-peptide (1.6 microg/mL) raised the suspicion of hyperinsulinaemic hypoglycaemia, so the patient was admitted to the Endocrinology Department. At the 1st day of hospitalization, the patient had another symptomatic hypoglycaemia at 14:00 h and new blood samples were collected confirming the previous results: plasma glucose 38 mg/dL, plasma insulin 10 microIU/L and c-peptide 1.9 microg/mL with negative anti-insulin antibodies. During hospitalization, the patient had multiple daily episodes of hypoglycaemia mainly during fasting, before dinner and at early night (Fig. 1) requiring intravenous infusion of 5-10% dextrose during the night period and frequent oral feeding during daytime. 2A).\nOUTPUT:" }, { "from": "agent", "value": "Pancreatic Insulinoma" } ]

[ { "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 case study, the interviews for which were carried out between August and September 2019 at a Swiss pharma company in the region provided further in-depth understanding of the reasoning and intentions behind the business travel. Ms. Silvana Micheli, a Swiss citizen native in German, Swiss-German and very high level of the English language, was trained by the researcher to perform the interviews on his behalf to avoid any bias or influencing the interviewees. Ms. Silvana Micheli is a Learning and Development professional in the pharma industry. In the organization, between 30 and 40 percent of all roles involve traveling. Overall, 15 employees were selected for the case study, a number which was felt to be sufficient for additional detail without risking data saturation. They were identified starting from the nominal description: gender, age, role grade and type of role and department. Only those with a role involving traveling were included. They were intentionally chosen to represent a broad scale of seniority and approached by email for their consent to participate in August 2019. At that time, they were informed of the nature of the study and the topic area, but not the research. An NDA (non-disclosure agreement) was issued and signed by representatives from the pharma company. The male researcher countersigned it to preserve the anonymity of the company and its employees. The data collected has been stored at SBS Swiss Business School safely and will be kept for five years. After this period, under the terms of the NDA the material including audio recordings of the interviews will be destroyed. An interview format was implemented with participants and questions were based upon the structure of the survey questionnaire to enable meaningful comparison of results. This gave the interviews a clear structure while allowing the possibility of extended answers and follow up questions as appropriate. Sessions were 45 minutes long, one on one, took place in the offices of the pharma company, and audio was recorded for the purpose of this research study only. The interviewer also took notes, manually writing down the answers to the interview questions. No repeat interviews were necessary. No participant refused to take part. Transcripts were not made available to participants. At the beginning of each interview the interviewer read the consent for audio recording and provided two copies to be signed. The interview audio analysis was part of a broader study than reported here.\nOUTPUT:" }, { "from": "agent", "value": "This case report does not contain a medical diagnosis as it is not a medical case report." } ]

[ { "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 74-year-old bedridden female patient was referred from the Department of Neurosurgery for the fabrication of the cranial plate. On examination, the defect was fronto temporo parito occipital. Since the margins could not be clearly defined and the patient was bedridden, hence a conventional moulage impression technique of the defect could not be carried out. A 3D printed model was planned for the case and CT scan of the defect was performed with slice thickness of 1 mm. The data was used to fabricate a 3D digital replica of the defect [Figure 13]. The data were then used to fabricate a model using stereolithographic technique using polylactic acid. A digital model of restoration of the defect was also attempted using the digital mirroring technique of the contralateral side. This restoration was then 3D printed using the same technique [Figure 14]. The model and reconstruction of the defect were then combined to observe the contour of the complete vault. Needed modification required were then carried using multi-utility wax. The pattern was invested directly and processed conventionally in heat-cured clear PMMA. PMMA graft was retrieved from mold, finished, and polished before drilling of holes in it. The graft was surgically screwed in place using titanium plates and mini-screws. The patient was evaluated after 3 wks for a favorable outcome of the graft and esthetic contour of the vault. The patient was reviewed after 6 months to find improvement of motor functions and the patient was able to walk with support.\nOUTPUT:" }, { "from": "agent", "value": "Decompression craniotomy, Severe edema" } ]

[ { "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: Female patient, 34 years old, caucasian, whose routine tomographic examination detected multiloculated hypodense lesion in the region of elements 31-34 (Fig. 1). In the intraoral physical examination, the patient presented buccal bulging, without complaining of pain or loss of vitality in the dental elements. When questioned, the patient reported a mild local trauma occurred 30 days earlier. Laboratory tests for calcium, alkaline phosphatase, and parathyroid hormone were requested and did not show alterations. The imaging examinations revealed, in the panoramic radiograph, the presence of circumferential radiolucent area with precise limits between dental elements 33 and 34, in the middle third and apical regions. Computed tomography showed an extensive hypodense image of 2.0 cm, unclear, expansive, and with undetermined aspect, located in the region of dental elements 32, 33, and 34. It also infiltrated the anterior myoadipose surfaces in the chin and oral space regions, suggesting a bone tumor lesion either malignant or with local aggressive behavior (e.g., osteosarcoma) (Fig. 2A and B). Considering this condition, an incisional biopsy of the lesion was performed under local anesthesia, in surgical block, which result showed a central giant cell granuloma (Fig. 3A-D). The team was composed of two PhD and a specialist in Buccomaxillofacial Surgery. Based on this result, the surgical approach was applied for lesion curettage, without regional bone resection. 4A-D). Thus, it was decided for the curettage of the entire lesion, also removing the prosthesis. For both biopsies, the patient was instructed to take amoxicillin (500 mg 8/8 h for 7 days) plus ibuprofen (600 mg every 6 h for 5 days). Post-intervention care was performed in the dental office. In the postoperative period, when questioned again, the patient reported having been subjected to aesthetic procedure around 10 months earlier, confirming the previous prosthesis installation. After 12 months of clinical and imaging control, bone repair and the absence of any sign of mandibular lesion were confirmed (Fig. 5A and B). The patient was instructed to return annually for postoperative control. The patient provided a written consent for the publication of this clinical case.\nOUTPUT:" }, { "from": "agent", "value": "Foreign body reaction" } ]

[ { "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: As previously reported, most of the tumors analyzed were squamous cell carcinomas (SCC), with a frequency of 386 (83.5%), followed by adenocarcinomas (ACC), adenosquamous cell carcinomas (ASCC), and undifferentiated carcinomas (IND), with frequencies of 63 (13.6%), 7 (1.5%), and 6 (1.4%), respectively. The distribution of HPV16 variants was radically different between the adenocarcinoma (ACC) and squamous cell carcinoma (SCC) groups (p < 0.001, Pearson chi-square test; Totals in Table 1). The percentage of the D variants was higher than that of A1/2 variants in the ACC (36.5% vs. 19%), whereas the reverse was observed in SCC (16.6% vs. 32.9%; p < 0.001, Pearson chi-square test). This difference was more evident when the <= 49 year-old groups were compared (p < 0.01, Pearson chi-square test). The median age of patients positive for different variants was similar between SCC and ACC (S2 Table). In both groups, D2-positive patients were younger than patients positive for other variants. Although the median of D2-positive patients with ACC (40, IQR: 33-49 years) was two years lower than that of patients with SSC who were positive for this variant (42, IQR: 35-55 years), the difference was not statistically significant. We considered the older patients (>= 50 years of age) as the reference of the outcome variable and non-HPV16 cases as the reference of the explanatory variable to investigate whether HPV16 variants are associated with early CC presentation (<= 49 years of age). D2 increased 3.3-fold the risk of developing CC before 50 years of age (OR = 3.3, 95% CI = 1.7-6.6, p < 0.001), in relation with non-HPV16 cases. Considering SCC and ACC cases separately (Table 1), this risk was higher for ACC (OR = 6, 95% CI = 1.1-33, p < 0.05) than for SCC (OR = 2.8, 95% CI = 1.3-5.9, p < 0.01). In contrast, A1/2 and D3 were not associated with any increased risk to develop CC before 50 years of age in relation with non-HPV16 cases.\nOUTPUT:" }, { "from": "agent", "value": "Cervical 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 ulcer had been present for around 4 months. Initial assessment revealed the wound measuring 5.5 cm long x 2 cm wide, necrotic with extensive fibrin deposits, heavily exuding, malodorous, and tender. There was erythema, eczema, and trophic changes of the surrounding skin [Figure 1]. Previous treatment was with removal of exposed reconstruction plate and primary closure [Figure 2a]. After extensive assessment, exudate was sent for culture and sensitivity test. The wound was cleansed with saline solution and a sterile hydrocellular dressing applied. The patient was hospitalized and IV linezolid 300 mg b.i.d for 7 days administered along with local wound debridement and periodic dressing. Healing was satisfactory and the patient was discharged a week later. Hydrating gel and cream were applied to the surrounding skin. Two-month later, the patient reported back with an ulcer on the same site [Figure 2b] which was bigger in size than the first reported. Culture sensitivity gave the same report of MRSA positive and sensitivity to linezolid. The treatment was same as before, but the second time, the ulcer did not show any progress in healing, rather the ulcer deteriorated further. The failure of conventional methods of repeated wound dressings prompted the use of Calgigraf Ag foam [Figure 3a and b]. Drastic reduction in the ulceration followed by improved healing was evident and the patient was recalled weekly to change the Calgigraf Ag foam dressing. By day 7, there was a significant decrease in exudate, odor, and necrosis, with the appearance of some granulation tissue. After a further 14 days [day 21] [Figure 4a and b], there was no longer any odor. The necrotic tissue and fibrin deposits had also disappeared, with significant amounts of new tissue growth and consequent reduction in wound area, depth, and amount of exudate. The evaluation on day 60, the area of wound was healthy, with no further signs of infection. Inflammation had decreased and the wound had reduced completely [Figure 5].\nOUTPUT:" }, { "from": "agent", "value": "Osteoradionecrosis, Adenoid cystic carcinoma of the left lower border of the mandible, Methicillin-resistant Staphylococcus aureus (MRSA) 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: The patient was born at 41 weeks fetal age by normal vaginal delivery; her birth weight was 3,200 g, and there was no history of neonatal asphyxia. She was apparentlyasymptomatic until the age of 5 years, when, after crying, her face went pale and her level of consciousness transiently decreased. A heart murmur and cough were noted during a medical check-up performed immediately after the event, and she was admitted to our hospital for further investigation. After a thorough examination, including ultrasound cardiography and cardiac catheterization (Table 1), she was diagnosed with idiopathic PAH. She had no family history of PAH. Genetic testing revealed no pathological variants in BMPR2, ACVRL1, ENG, SMAD9, CAV1, KCNK3, and EIF2AK4, which are the genes responsible for heritable PAH. Although beraprost, sildenafil, and bosentan were administered, her dyspnoea continued to worsen, and she developed pulmonary hypertensive (PH) crisis. Three months after the initial diagnosis, she underwent cardiac catheterization to facilitate the initiation of epoprostenol therapy. When intravenous anesthesia was administered prior to the insertion of the cardiac catheter, she suffered an acute PH crisis again and went into cardiopulmonary arrest. Two days after she was weaned off cardiopulmonary support, a computed tomography scan of the head revealed extensive cerebral infarction. Hypoxic encephalopathy was confirmed, and tracheostomy, central venous (CV) catheter implantation, gastrostomy, as well as Nissen fundoplication were subsequently performed. Thereafter, the patient was transferred to a long-term care facility, where she was followed up with increasing doses of epoprostenol, bosentan, and sildenafil. At the age of 6 years, beraprost was discontinued.\nOUTPUT:" }, { "from": "agent", "value": "Idiopathic Pulmonary Arterial Hypertension" } ]

[ { "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 patient was a 47-year-old woman:with a past medical history of SLE, a known stable AAA, previous left SFA-to-peroneal bypass, HTN, HLD, DM, and CKD:who presented to the Emergency Department with acute-onset of periumbilical abdominal pain. She endorsed nausea and nonbloody emesis and denied any radiation of her pain. The patient was scheduled for routine follow-up the following day with her vascular surgeon for her known AAA, which was measured at 4.5cm six months prior. Her AAA had yet to be operated on and had been managed conservatively with medical management of her comorbidities. She took warfarin \"for lupus,\" and it is unclear whether this was due to an associated hypercoagulable state such as antiphospholipid antibody syndrome. She was a nonsmoker and did not use any illicit substances. Shortly following her presentation to the ED, the patient suddenly lost consciousness. She was immediately taken to the medical resuscitation bay, where she was unresponsive with depressed respirations. Mechanical ventilation was initiated and an eFAST ultrasound revealed a small amount of free fluid in the pelvis. The patient subsequently lost pulses, and CPR was immediately initiated. Two liters of normal saline were administered, epinephrine was given, and crash blood was administered. A repeat FAST exam showed accumulating blood within the peritoneum and the patient's abdomen was noted to be growing progressively distended. Significant laboratory abnormalities included an H/H of 4.9/15.8, INR 1.7, and Creatinine of 1.9. A massive transfusion protocol was initiated and multiple specialty services were called to the bedside, including trauma surgery, vascular surgery, and cardiology. However, despite maximal resuscitative efforts, the patient failed to regain pulses and was declared deceased after 58 minutes of aggressive resuscitation.\nOUTPUT:" }, { "from": "agent", "value": "Catastrophic AAA Rupture, Systemic Lupus Erythematosus" } ]

[ { "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 Japanese women presented to our institute due to abnormal chest computed tomography (CT) findings showing a 45 x 40 x 40-mm tumor located in the anterior mediastinum. This tumor was composed of cystic and solid lesions (Fig. 1). The patient had no remarkable medical history. Laboratory tests showed no abnormal findings but an elevated serum carcinoembryonic antigen (CEA) level, and abdominal CT also showed no abnormal findings. The mediastinum tumor was suspected to be malignant based on the CT findings and elevated CEA level; however, a definite pathological diagnosis for the tumor could not be made before the surgery. The tumor was resected local completely via VATS through the left thoracic approach. In the left thoracic cavity, a few small nodules were found. We resected these nodules. This patient discharged healthy from our institute at six days post-operation. Pathologically, the tumor consisted of two separate components. 2a). There was no evidence of mucin production, nor were there any Hassal's corpuscles around the tumor, but it was continuous with the thymic tissue. Immunohistochemical (IHC) staining was positive for MUC1, EMA, CD5, p63 and bcl-2 but negative for TTF-1, calretinin and thrombomodulin (Fig. 2b-d). The MIB-1 index was 70%. This tumor consisted primarily of spindle-shaped epithelial cells and many lymphocytes without atypia (Fig. 2a).\nOUTPUT:" }, { "from": "agent", "value": "Thymic papillary adenocarcinoma, Type A 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: A 52-year-old female was admitted to Baqiyatallah Hospital, Tehran, Iran, in 2015 with a history of seven-month generalized abdominal pain slightly more in the epigastrium, accompanied by nausea and vomiting. She had a history of intermittent abdominal pain, recurrent nausea and vomiting, inability in gas passing, and constipation with at least ten times of hospitalization during the past three years. Her past medical history was significant for asthma, tubal ligation and umbilical hernia surgery, cholecystectomy, diagnostic laparoscopy, and simultaneous appendectomy. At the admission, vital signs were the pulse 85 beats per minute; temperature 37.2 C, and blood pressure 110/75 mmHg. Abdominal examination revealed generalized tenderness with preference in the epigastric and right abdomen without rebound and guarding, and it was distended slightly. Her rectal examination was normal. White blood cell (WBC) count was 9900/mm3 with 24% lymphocytes; hemoglobin was 16.1 g/dL, and hematocrit was 46.6% (normal: 35.9-44.6). All biochemistry tests were in normal range. Endoscopic findings showed bile reflux, erythematous gastritis, and stomach body ulcer. Abdominal sonography study was normal. Abdominal CT scan showed torsion around the narrow mesenteric stalk (Figures 1(a) and 1(b)). Abnormal findings included positioning of the duodenojejunal flexure to the right of the spine, obstruction of the duodenum, and \"beak\" appearance of the obstructed proximal jejunum (Figures 2(a) and 2(b)). She remains asymptomatic 5 months after surgery (Figure 3).\nOUTPUT:" }, { "from": "agent", "value": "Midgut Volvulus" } ]

[ { "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 69-year-old man with stage IV DLBCL who presented for syncope and worsening weakness. On admission, the patient tested positive for COVID-19 (PCR), and a few days later he experienced worsening respiratory distress. Throughout his admission, the patient remained febrile and required an increasing oxygen supplementation. Subsequent COVID-PCR lab results over the next 3 months persistently tested positive. Repeat computed tomographic (CT) scans showed worsening bilateral opacities (Figures 1-3). The Infectious Disease service believed that the patient had chronic inflammation from prior COVID-19 infection. The patient's COVID-19 PCR cycle threshold was elevated at 35, indicating a low viral load. Given that the initial COVID-PCR positive result was 3 months prior, the Infectious Disease team did not believe that the patient was having an active COVID-19 infection and that the patient was not contagious. A thorough infectious workup was nonremarkable. Fungal studies, such as cultures, beta-d-glucan, and histoplasma, did not yield any significant results. A bacterial workup was also negative, which included repeated blood and sputum cultures for Legionella, Bordetella, Chlamydia, Mycobacterium, and Mycoplasma. Other viruses were also ruled out, including adenovirus, influenza, parainfluenza, metapneumovirus, and even coronavirus strains that are not COVID-19. The patient's clinical status continued to deteriorate, desaturating to 83% on 5 L of nasal cannula. The patient eventually required 15 L of high-flow. The intensive care unit was consulted, and they recommended a steroid taper starting with prednisone 40 mg for 1 week, subsequently decreasing by 5 mg every 7 days. The patient's oxygen requirement decreased to 5 L of nasal cannula. A repeat CT thorax demonstrated extensive pulmonary edema, as well as early pulmonary fibrosis (Figure 2). At the time, no established guidelines existed for the treatment of PC-ILD. We then decided to treat for PC-ILD with a higher dose of oral steroids. The patient received methylprednisolone 70 mg twice a day for 3 days. The patient's respiratory status improved and he required less oxygen, eventually de-escalating to 4 L of nasal cannula. A CT thorax was repeated and showed an interval improvement in pulmonary edema, revealing a more extensive pulmonary fibrosis (Figure 3). A discussion regarding goals of care was conducted, and the patient was discharged to home hospice.\nOUTPUT:" }, { "from": "agent", "value": "Post-COVID Interstitial Lung Disease, Diffuse Large B-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: She had suicidal thoughts intermittently since age 25 years and had made three suicide attempts in the past. Ms. A lived in an apartment in a social housing complex. Six weeks before her death, Ms. A discovered bed bugs in her apartment. An exterminator was called, but four weeks later there was another infestation. During the second visit, the exterminator recommended that all her clothes be placed in plastic bags for three weeks, before a third fumigation of the apartment. Having developed a phobia of the bed bugs, Ms. A requested help to be relocated but could not be accommodated. She also resumed her consumption of alcohol, which increased following her losses at the casino. On the night of her death, she awoke at 3 am and found a drop of blood on her dressing gown. She was convinced the bed bugs had returned and wrote a note stating that she had been depressed since their arrival and would be going to a better world. She also wrote an email to a friend a few minutes before killing herself: \"I am panicking now because I just saw a drop of blood on my dressing gown sleeve and I am sure that vampires are back and I cannot stand to live in fear of me being eaten alive... I cannot stand it and I chose to take my life... At the time of writing, I have swallowed a bottle of wine and two hundred pills and I feel nothing, I feel completely empty, it is unbearable...\" [authors' translation]. When she called to notify her employer that she would be absent from work, he picked up on her distress and immediately called 911. The police arrived and found Ms. A on her balcony on the 17th floor. Efforts to dissuade her from jumping were unsuccessful and she died instantly with multiple injuries to the brain, thorax and pelvis as a result of her fall.\nOUTPUT:" }, { "from": "agent", "value": "Bipolar disorder, Borderline personality, Chronic alcoholism, Gambling addiction" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 21-year-old woman was referred to the Urology Department for management of a high-grade invasive urothelial carcinoma of the urinary bladder, reported on a biopsy performed outside. The only morphological examination was done, and immunohistochemistry (IHC) had not been performed. She had a single episode of gross painless hematuria one month back, for which she had been evaluated. On evaluation, she was asymptomatic, with no remarkable physical examination. Her pulse was 76/min, blood pressure was 110/70mm Hg, and respiratory rate was 18/min. Her blood and urine workup were within normal limits. The abdominal and pelvic contrast-enhanced computed tomography (CT) revealed a nodular and polypoidal enhancing mass from the right posterior wall of the urinary bladder (Figure 1). The initial biopsy was reported elsewhere as a high-grade invasive urothelial carcinoma, and the blocks and slides were reviewed. Sections showed the bladder, focally lined by urothelial lining, with a tumor in the lamina propria, arranged in nests and trabeculae separated by thin fibrovascular septae, with 'Zellballen pattern' (Figure 2A). The tumor cells were large, with moderate to abundant amounts of eosinophilic granular cytoplasm, round to oval nuclei, stippled chromatin, and inconspicuous nucleoli. Mitoses were <2/10 high power fields, and necrosis was not identified. The deep muscle was not included in the biopsy. On immunohistochemistry (IHC), the tumor cells were diffusely and strongly positive for chromogranin and synaptophysin. S100 protein was positive in the periphery of the nests in the sustentacular cells (Figures 2B-D). The tumor cells were negative for CK7, CK20, and p63, ruling out a urothelial neoplasm. Ki-67 proliferation index was <2%. Urinary and plasma nor-metanephrine, metanephrine levels, and urinary VMA levels were within normal limits. Patient was advised for an MIBG scan/ Gallium 68 DOTANOC PET/CT scan; however, it was not done due to affordability issues. No other lesion was found on a routine radiology scan (CT scan). Following the biopsy report, a partial cystectomy was received, which showed similar features. The patient is on follow-up (12 months to date) and doing well.\nOUTPUT:" }, { "from": "agent", "value": "Paraganglioma" } ]

[ { "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: Babyloid, modeled on the beluga whale, is a baby robot that shows potential for interactive doll therapy. It can perform facial expressions with six types of emotions and multimodal reactions such as the recorded voice of a one-year-old and body movements. In a two-week experiment with five healthy seniors, their interaction with Babyloid averaged about 7 min, and their scores on the Geriatric Depression Scale (GDS), which measures depression, improved after the experiment. In addition, although various features have been implemented, no functional requirements have been explored. We developed a tele-operated android named Telenoid based on a minimal human design approach to support communication with older people. Telenoid only has minimal functions for communication and a simple movement mechanism for its arms, neck, and mouth. It has no function for emotional expression, although it does have eyes, a nose, and mouth. Its appearance is gender neutral and ageless. However, the human operator's voice information conveyed from Telenoid allows users to project personal traits and emotional states onto it. Such touch interactions probably increase the intimacy between older people and robots, and strengthen their social bonds. On the other hand, a human operator is required since Telenoid is a tele-operated robot. In addition, previous studies have shown that many such seniors treat Telenoid like a toddler even when adult care personnel tele-operated it, suggesting that a more child-specific design that stimulates their imagination through simple communication may be sufficient. Therefore, we designed an interactive baby robot based on a minimal design approach.\nOUTPUT:" }, { "from": "agent", "value": "Dementia" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: Patient 2 was a 19-year-old 56.5-kg male admitted on 10/18. He presented with increased cough and sputum production and decreased PFTs for the past month. A chest X-ray was obtained on admission which revealed increased mucus plugging and coarse lung markings that were most prominent in the right upper lobe. The admission BUN and SCr values were 9 and 0.81 mg/dL, respectively. The most recent sputum culture from 10/10 grew three strains of few P. aeruginosa. He was treated with ceftazidime 2 g IV every 8 h and tobramycin 560 mg IV every 24 h (9.9 mg/kg/dose). Following the first dose on 10/18, a 2-h level was reported as 26.4 mg/L, but because it was suspected to be erroneous, the 10-h level was not obtained. The levels were therefore reordered with the next dose. Tobramycin serum levels that were collected after the second dose on 10/19 indicated that the 2-h level was 33.1 mg/L (Table 1). However, prior to collection of the 10-h post-dose level, the analyzer error was discovered and corrected. Therefore, because of the analyzer error and because the levels were extremely dissimilar to the patient's historical serum concentrations, the dose was not adjusted and the levels were again repeated. Following the 10/20 dose, the 2- and 10-h levels were 23.2 and 1.3 mg/L, respectively, yielding an extrapolated peak and AUC that were slightly elevated (Table 1). The dose was decreased 15%, resulting in the 2- and 10-h levels of 18.9 and 1.2 mg/L, respectively, yielding serum tobramycin concentrations that were within the target range (Table 1). The patient was continued on this dose for the remainder of his hospital stay. He demonstrated improvement in pulmonary function and no signs/symptoms of aminoglycoside toxicity and was discharged to home after completing his antibiotic course.\nOUTPUT:" }, { "from": "agent", "value": "Cystic Fibrosis" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 79-year-old man visited a clinic with a month-long history of dysphagia. 1a, b). There were metastases to regional lymph nodes, but there was no evidence of distant organ metastases. Three weeks later, the patient was transferred to our hospital and was examined in detail. 2a, b). Blood tests showed an increased white blood cell (WBC) count of 9600/mm2 and a C-reactive protein of 13.43 mg/dL (Table 1). Due to the presence of the EPF, the patient underwent emergency surgery that consisted of esophageal separation surgery and double bilateral esophagostomy and enterostomy. 3a, b). Radiotherapy was performed with a total dose of 46.8 Gy. Chemotherapy consisted of cisplatin (CDDP) and 5-fluorouracil (5-FU) therapy in 2 courses. At 90 days after surgery, the patient was discharged from the hospital. At six-month follow-up, the patient had achieved relapse-free survival and is currently symptom-free.\nOUTPUT:" }, { "from": "agent", "value": "Advanced esophageal cancer, Respiratory fistula, Lung abscess, Pneumonia, Sepsis due to aspiration 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: On D18 a life-threatening deterioration with clinical symptoms of shock occurred, the baby was intubated, and mechanical ventilation was initiated. Echocardiography was performed and showed a large tumor formation in the right atrium 2 x 2.3 cm, reduced blood flow into the right ventricle and pulmonary artery, and minimal pericardial effusion (Figure 1). The patient was immediately transferred to the pediatric cardiology clinic and admitted with unstable hemodynamic parameters, on conventional mechanical ventilation (Synchronized Intermittent Positive Pressure Ventilation, FiO2 1.0) with arterial oxygen saturation of 74%, along with moderately increased lactate levels; an enlarged liver was palpated up to the level of the umbilical horizontal line. These data suggested impaired systemic venous drainage. An additional echocardiographic examination was performed and revealed an infiltration growth of the tumor to the tricuspid valve and the right ventricle. The enormous tumor formation filled the entire right atrial cavity. Our first hypothesis was that the tumor formation was a myxoma of the right atrium, with a differential diagnosis for rhabdomyoma or thrombus. Based on the data known so far and the hemodynamic instability, a decision was made for immediate surgery. Pre-operative echocardiography also demonstrated an atrial septum deviation toward the left atrium and a Foramen ovale communication with a right-to-left shunting. Pulsed Wave Doppler (PW Doppler) velocity through the tricuspid valve was 1.4 m/s with a mean RA-RV gradient of 4 mm. PW Doppler velocity across the pulmonary valve was 0.6 m/s.\nOUTPUT:" }, { "from": "agent", "value": "Cardiac Myosarcoma" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 71-year-old Hispanic woman with history of diabetes mellitus and hypertension presented with slowly progressive constipation for 6 months, mild, dull, nonradiating, lower abdominal pain, increased abdominal girth, and 50-pound weight loss. A computed tomography scan of the abdomen and pelvis demonstrated a large 18.9 x 12.8 x 12.5 cm heterogeneous mass originating either from the right adnexa or the intestine (Figure 1(a)). The serum tumor markers were CA19.9: 119 U/mL and CEA: 7.2 ng/mL. A colonoscopy revealed a necrotic mass located at 25 cm from the anal verge. She underwent a hysterectomy with bilateral salpingoophorectomy and partial colectomy. Gross examination of the specimen revealed an 18 cm cystic mass, attached to a 14 cm segment of the colon. The cyst was filled with tan sebaceous material and black hair and was attached to the colonic wall, where a firm white 11 cm solid mass was noted (Figure 1(c)). The tumor cells were positive for p63 (Figure 1(e)) and negative for p16 (Figure 1(f)) by immunohistochemistry. The patient was deemed to be stage IIB and underwent 6 cycles of adjuvant chemotherapy with carboplatin and Taxotere. The tumor markers were still elevated one month after surgery; CA19-9 was 106.7 U/mL and CEA was 4.62 ng/mL. Two months later, an abdominal and pelvic CT scan revealed a new bilobed 5.5 cm mesenteric mass in the right hemipelvis, which was not separable from the adjacent bowel loops, an enlarged soft tissue mass in the left iliac fossa, and a subhepatic mesenteric mass. The patient declined any type of additional chemotherapy, moved to a different city, and was lost in follow-up.\nOUTPUT:" }, { "from": "agent", "value": "Malignant Transformation of Ovarian Mature Teratomas, 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 32 year old lady presented to emergency medical room (EMR) at early morning hours (4.00 am) with sudden onset of high grade fever, tachycardia and breathing difficulty. The patient was intubated with endotracheal tube and put on ventilator and supportive therapy was initiated. A provisional diagnosis of septicemia was made and samples were sent for blood culture and urine culture. The patient was started on intravenous antibiotics and antipyretics. Cerebrospinal fluid tap was done and sample sent for culture and evaluation. Chest X-ray was done which did not show any active infective lesion. White blood cell (WBC) count was higher - 18000 per cu mm. Rest of the parameters were normal. The patient stabilized and improved over the next 48 hours. After gaining orientation, the patient complained of decreased near vision. Pupils were noted to be mid-dilated, not reacting to light. On detailed ocular examination, best corrected visual acuity (BCVA) was 6/6 OU and N/6 OU, optic disc was normal and no ophthalmological abnormality was detected except semi-dilated non - reacting pupils. The WBC count decreased to 11000 per cu mm on day 2 and to 8000 per cu mm on day 3. The blood culture, urine culture and CSF culture reports were negative. The patient completely recovered except for semi-dilated pupils noted on day 4,5 and 6. On detailed history, it was noted that the patient was apparently normal 4-6 hours prior to presentation at the hospital. At midnight, on the night of presentation, she showed symptoms of uneasiness, tachycardia and breathing difficulty and was admitted in ICU. The symptoms appeared over 2 to 4 hours. The patient gave history of visiting the farmland areas and chewing some berries fallen on ground in the preceding afternoon. Considering that we could not elicit any sign of septicemia except for elevated WBC count, the diagnosis of septicemia was questionable. The records of the EMR did not show any pupillary reflexes. Study was conducted after obtaining an informed consent form from patient.\nOUTPUT:" }, { "from": "agent", "value": "Atropine poisoning" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A healthy 34 year old woman presented to medical attention after experiencing several days of moderately severe pleuritic chest pain without other respiratory or constitutional symptoms. She was Ecuadorian where she lived until the age of 5 and had not recently been, worked at a local supermarket (although not in food handling capacity) and had moderate persistent asthma well controlled on combination long acting beta-agonist and medium dose inhaled corticosteroid. Contrast CT scan of the chest demonstrated several bilateral pulmonary nodules without infiltrate, adenopathy or effusion. The largest was 1.5 x 1.5 cm in the left upper lobe with cavitation (Fig. 1). Active tuberculosis was ruled out. Blood cultures were negative and transthoracic echocardiogram did not demonstrate valvular vegetations. Nonspecific inflammatory markers were elevated: C-rp 61 mg/L (normal range: 0-3) and ESR 28 MM/h (normal range: 0-22) and ANA was positive with titer 1:80; however, ANCA were within the normal range. She did not have a leukocytosis (WBC 8300/uL). Serologic evaluation for fungal disease was negative. She had a mild transaminitis with alanine aminotransferase > aspartate aminotransferase and imaging of the liver via ultrasound and CT scan revealed steatosis without discrete lesions. Expectorated sputum grew Mycobacterium avium complex; however the clinical scenario seemed largely incompatible. Airway examination on bronchoscopy and bronchoalveolar lavage were also unrevealing. The patient underwent a surgical biopsy of the left upper lobe nodule - our leading diagnostic consideration of which at the time was seronegative pulmonary vasculitis. Pathology did not show granuloma, malignancy or AFB; rather, was an abscess (Fig. 3). Notably, she had no upper respiratory symptoms, neck pain, febrile illness or dental work around the time of this presentation. On further detailed questioning she recalled a sore throat 5 months prior without fever, and enjoyed several months of good health in the intervening time. CT of sinus/neck were normal and in fact, on repeat chest CT several weeks later lung nodules contralateral to biopsy and prior to any therapy were smaller in size (Fig. 2). We elected to treat with ertapenem for 6 weeks and CT scan after therapy showed resolution of all dominant nodules. Of note, chest pain resolved well prior to initiation of therapy and has not recurred.\nOUTPUT:" }, { "from": "agent", "value": "Fusobacterium necrophorum" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 71-year-old male with no significant medical history was scheduled for elective laparoscopic sigmoidectomy eight weeks after resolution of an episode of perforated diverticulitis. After inducing general anesthesia, cystoscopy with insertion of bilateral ureteric stents was performed by the Urology Service. After mobilization of the left colon, the left ureter was identified as crossing the left iliac artery and continuing cephalad, seemingly into the retroperitoneum; the inferior mesenteric artery was then identified and divided. The distal end of the ureter was completely transected and sealed. Gerota's fascia was identified and incised medially, after which the plane posterior to the ureters, between the psoas and the kidney, was developed. The left kidney was mobilized by dividing the lateral attachments and the hilum was identified. The renal pelvis was identified below the renal vein and was followed to the proximal cut edge of the ureter. Both ends of the ureter were debrided and spatulated. The anterior portion of the anastomosis was completed with 4.0 polyglycolic acid interrupted sutures. The anastomosis appeared watertight. Jackson Pratt (JP) drains were left in the retroperitoneum. The patient was discharged home on the sixth postoperative day.\nOUTPUT:" }, { "from": "agent", "value": "Ureteral Injury" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: She was a known case of DCM since 11/2 years. She gave a history of hospital admission 5 months ago with features suggestive of congestive heart failure. Her symptoms were well-controlled on treatment with oral frusemide, spironolactone, digoxin, ramipril and carvedilol. On examination, her heart rate was 88/min and blood pressure of 106/66 mmHg. There were no features suggestive of congestive cardiac failure. A 12 lead electrocardiography (ECG) showed normal sinus rhythm and T-wave inversion in leads III and aVF. Chest X-ray revealed cardiomegaly. The ECG showed LVEF of 20%. Routine laboratory investigations were normal with hemoglobin level of 10.7 g%. High-risk consent was taken from the patient and regional anesthesia technique explained. Combined spinal-epidural anesthesia was planned. After taking patient in the operating room, pulse oximetry, ECG and non-invasive blood pressure monitors were applied. After securing intravenous line, left radial artery and right internal jugular vein cannulation was also carried out under local anesthesia. Under all aseptic precautions, a combined spinal epidural block was given. Sub arachnoid block with 7.5 mg of 0.5% bupivacaine heavy along with 25 mug fentanyl and 0.3 mg of morphine attained a sensory level of T5. It was associated with hypotension with blood pressure of 76/40 mmHg, which was managed with intermittent intravenous boluses of 3 mg ephedrine. Surgery lasted 45 min. Central Venous Pressure (CVP) ranged from 7 to 9 cm H2O. Her post-operative course in high dependency unit for 1 day and further in ward till discharge was uneventful.\nOUTPUT:" }, { "from": "agent", "value": "Dilated Cardiomyopathy, Acute Appendicitis" } ]

[ { "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 the contrary, teachers' demographic background information shows about 57% are male teachers and 43% are female respondents, most of them are in the age of 27-33 years old and have served for more than 5 years. About 84% are from the other discipline/teaching other subjects and only 16.0% of the respondents listed are trained PE teachers, who due to lack of interest and future of the PE teacher found the least attractive option to become PE teacher, therefore they do agree with the statement of lack of interest and future opportunities oppressing them to not become PE teacher in the school. In the third phase of the project, as mentioned in the research design stage, data were collected from the students and teachers. Mean of the all question is low as compared to their variances, and the bigger value of variances means more distraction, deviation, and non-conformance to the needs and requirements. It simply means that students are not satisfied with the present state of PE. The teacher's data also portray the almost same situations as predicted by the students' data as listed in Table 2. Availability of facilities (AF), Trained Professional Physical Teacher (TPPT), State Supports for Physical Education (SSPE), Support from Management (SM), Miscellaneous Problem of PE (MP), and Student Related Problems (SRP) all constructs have small mean values as compared to variances, which indicate that teachers are not happy from the conditions of the physical education facilities and support activities. According to the results of the two-sample t-test, there is very less variation among the means of the two samples, which shows homogeneity of the samples (Table 3). Similarly, both P-values are less than 0.05, which indicates their significance followed by the values of Cronbach alpha. These values also proclaim the reliabilities, validity, and consistencies of the instrument. So, according to the results, the conditions of the t-test meet and remain valid for the study.\nOUTPUT:" }, { "from": "agent", "value": "This case report does not provide information about a medical diagnosis." } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: The delivery was uncomplicated with no instrumentation. He was intubated and mechanically ventilated at birth. There was no known family history of connective tissue disorders, cataracts or easy bruisability. There were no dysmorphic features, joint hypermobility, or cutis laxa. His cardiac examination was also normal with no hypertension. The superior \"arch\" coursed leftward, with the right common carotid and subclavian arteries arising from it, while the hypoplastic arch coursed inferiorly giving rise to the left common carotid and subclavian arteries (Figures 2E-G). The maximum velocity across the descending aorta was estimated at 4.59 m/s (pressure gradient 99.9 mmHg). However, the neonate had normal cardiovascular examination with no differential pulse or blood pressure between upper and lower extremities. The umbilical artery catheter (UAC) (Figure 1) was incidentally noted to have a tortuous course on radiograph on D5 of life (Figure 2A). The left common carotid and subclavian arteries arose from the hypoplastic transverse arch. The pulmonary veins were normal (Figure 2D). The UVC was also tortuous as evidenced in the abdominal roentgenogram.\nOUTPUT:" }, { "from": "agent", "value": "Neonatal Arterial Tortuosity, Adult Aortic Aneurysm, Hydrops fetalis, Bilateral pleural effusions, Subcutaneous oedema, Multiple fractures involving ribs and left clavicle, Comminuted right parietal skull fracture, Bilateral inguinal hernia, Double aortic arch, Dilated and tortuous right brachiocephalic artery, Dilated and tortuous thoraco-abdominal aorta and branches of the coeliac axis, Unusual branch pulmonary arteries, Dilated and tortuous abdominal aorta and the celiac axis branches." } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 58-year-female was admitted to local hospital due to anorexia, nausea, vomiting, and malaise for 1 month. She also complained of palpitations, insomnia, diarrhea, and chest tightness; however, she denied any bone pain. She had lost 15 kg of weight in the month before admission. Her past medical history showed hypertension for 5 years and a cerebral infarction 1 year earlier. She took nitrendipine 10 mg 3 times a day to control her hypertension and denied taking any other medications. Laboratory findings showed a significantly elevated free T3 of 15.7 pmol/L (FT3, normal range: 3.1-6.8 pmol/L), elevated free T4 of 36.6 pmol/L (FT4, normal range: 10.3-22.6 pmol/L) and reduced thyroid stimulation hormone of 0.011 muIU/mL (TSH, normal range: 0.27-4.20 muIU/mL). Electrolyte tests showed markedly high serum calcium of 2.99 mmol/L (normal range: 2.08-2.80 mmol/L) and normal serum magnesium, sodium, potassium, and phosphate concentrations. Her serum creatinine was 118 mumol/L (normal range: 45-104 mumol/L), urea nitrogen 9.73 mmol/L (normal range: 1.84-7.14 mmol/L), and uric acid 511 mumol/L (normal range: 155-428 mumol/L). The patient's blood, urine, and stool examinations were all normal.\nOUTPUT:" }, { "from": "agent", "value": "Hyperthyroidism, Hypercalcemia" } ]

[ { "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 34-year-old woman with sudden onset of generalized abdominal tenderness was transferred from an outside hospital. Her history was significant for multiple prior admissions for abdominal problems, the first of which was for an ischemic bowel in 2005, which was treated with an ileo-colic anastomosis. She presented again in 2013, shortly before her current admission, and CT scan revealed two nodules in the liver, a nodule in the left adrenal gland, and an umbilical hernia. Her history was also significant for volvulus, multiple gastric ulcers, and a tubular adenoma found on colonoscopy. When she arrived to our hospital in August of 2013, her physical exam was significant for diffuse abdominal tenderness. She reported that her last bowel movement was earlier on the day of admission. An abdominal CT was ordered, which showed multiple dilated loops of bowel and three distinct target signs (Fig. 5), as well as significant mechanical traction of the distal small bowel. The patient was taken to the operating room for an exploratory laparotomy. 6). The affected portion of bowel was resected, and a jejunojejunal anastomosis was created. An area of narrowed ileum was discovered near the ileocolic anastomosis previously created after her episode of ischemic bowel. Mesenteric foreshortening was noted throughout the bowel as were multiple fibrotic implants. An internal hernia and an umbilical hernia were noted, though they did not appear to act as lead points, and subsequently reduced. The patient had no apparent complications from the procedure and recovered well. She was discharged on post-operative day 8 and was followed up in clinic as an outpatient.\nOUTPUT:" }, { "from": "agent", "value": "Intussusception, Carcinoid tumor" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 16-year-old girl presented to emergency room with complaints of weakness of right upper limb and lower limb for an 18-hour duration. She also had facial deviation towards left side. She had inability to produce and comprehend the speech. There was no history of fever, head trauma, and seizure. She had no significant past medical history and family history. She was nonsmoker and never consumed alcohol. At emergency room, her Glasgow coma scale score (GCS) was 11/15(E4V1M6). Her blood pressure was 110/80 mmHg, pulse rate 80 beat per minute in left radial artery and absent pulse in right brachial and radial artery, respiratory rate -16 cycle per minute, temperature -98 F. Central nervous system examination revealed right sided hemiplegia, global aphasia, and upper motor neuron type facial nerve paralysis. Other central nervous examination and systematic examination findings were normal. The baseline investigation reports were illustrated in Table 1. Computed tomography of head showed hypodensity at left frontotemporoparietal region along with middle cerebral artery dot sign (Figure 1). Ultrasonography Doppler revealed thickening of right common carotid, right internal carotid, right external carotid, and right subclavian artery with significant lumen obstruction. Computed tomographic aortogram revealed circumferential thickening of arch of aorta, brachiocephalic trunk, and right common carotid (Figure 2). Electrocardiogram, Chest X-RAY, Ultrasound abdomen and Echocardiography was normal. She was treated with tablet aspirin 75 mg once daily, tab, and prednisolone 40 mg once daily. Physiotherapy was initiated on second day of admission. She was discharged from hospital on tenth day of admission on prednisolone and aspirin. At the time of discharge her stroke disability modified ranking scale was 3/5.\nOUTPUT:" }, { "from": "agent", "value": "Malignant Ischemic Stroke, Takayasu Arteritis" } ]

[ { "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 man with an extragonadal GCT of mediastinal origin complained of right homonymous hemianopia and was referred to Shinshu University Hospital for the treatment of the brain metastasis. The brain lesion had grown rapidly (Fig. 1), and serum tumor markers were elevated, including lactate dehydrogenase (LDH) at 447 U/l (normal, 118-236), alphafetoprotein (AFP) at 480 ng/ml (normal 10), and human chorionic gonadotropin (HCG) at 629 IU/l (normal 1.0). The patient had immediate neurosurgery to remove the tumor. 2). The patient also received whole brain radiation therapy (WBRT) (total 30 Gy/10 fractions) and adjuvant chemotherapy consisting of two courses of VIP therapy (etoposide, ifosfamide, and cisplatin). All tumor markers normalized. The residual lung tumors were resected, and no tumor remnant was seen on pathology. One month after lung surgery, the patient developed lumbago and a gait disturbance. 3A). Salvage chemotherapy, consisting of combination irinotecan and nedaplatin therapy, was given. 3B). However, the serum HCG elevated again, and recurrent cerebral ventricular and meningeal lesions appeared within a short period of time. Despite the use of additional salvage chemotherapy involving three courses of TIN therapy (paclitaxel, ifosfamide, and nedaplatin), in combination with the peripheral blood stem cell transplantation, the patient died due to disease progression 12 months after the initial brain surgery.\nOUTPUT:" }, { "from": "agent", "value": "Leptomeningeal metastases, Extragonadal germ cell tumor, Metastatic embryonal carcinoma, Yolk sac tumor" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: Plaque type psoriatic lesions were present on the scalp, especially in the left temporo-parietal region. Patient's psychopathology was assessed using auditory hallucinations subscale (AHS) of Psychotic Symptom Rating Scales (PSYRATS) and the score was 35. In view of persistent auditory hallucinations and considering the risk benefit ratio, the option of tDCS as an add-on treatment along with antipsychotics was considered. The patient as well as his primary caregiver was provided with adequate information regarding the procedure, and a video of the tDCS procedure was also shown. tDCS procedures were done using a standard equipment (Neuroconn DC Stimulator Plus, http://www.neuroconn.de/dc-stimulator_plus_en/) as per established guidelines with stringent safety measures. The anode was placed with the middle of the electrode over a point midway between F3 and FP1 (left dorsolateral prefrontal cortex) and the cathode located over a point midway between T3 and P3 (left temporo-parietal junction). The stimulation level was set at 2 mA for 20 minutes. The sessions were conducted twice a day (separated by at least 3 hours) on 5 consecutive days. At the end of each session, a structured questionnaire was used to assess for any potential adverse effects. In addition to this, the skin under the electrodes was examined for any lesion after each session. After second day, patient started reporting improvement in symptoms. He appreciated a significant decrease in duration and frequency of auditory hallucinations. Repeat AHS score on day 5, at the end of 10th session was 25. Subjectively, the patient reported significant improvement in the distress due to hallucinations. Assessment of adverse effect revealed only tingling sensation (restricted to the time of electrode application) which was rated as mild and tolerable by the patient. There was no erythema or burns at the electrode site.\nOUTPUT:" }, { "from": "agent", "value": "Alcohol-Induced Psychotic Disorder, Psoriasis" } ]

[ { "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 27-year-old Saudi man presented to our clinic in 2011 with a 2-day history of severe anxiety, fearfulness, and tremors that kept him home-bound and dependent on his family for the majority of his needs. He was unable to attend college or pray in Masjid. He reported a history of sudden, severe anxiety attacks over the prior 2 years, each lasting for 2 to 3 days. The attacks recurred monthly without clear triggers. He reported a bad and vague burning-clothes-like smell during the attacks, and he recovered his normal clinical state between them. One year earlier, he consulted a psychiatrist, who prescribed 40 mg paroxetine once daily. However, his condition deteriorated, and he began experiencing attacks twice monthly. He denied a family history of mental illness, but a cousin was diagnosed with epilepsy. The patient denied drug misuse. Examination revealed anxiety, fearfulness and postural tremor with no other positive neurological findings. His thinking and cognition were normal. The inter-ictal EEG at this time (patient was symptom-free) did not show abnormalities. Clinical findings suggest epileptic attacks with dys-osmic expression. Paroxetine was discontinued, and the patient dramatically improved (no more attacks) on 400 mg carbamazepine twice daily. This was continued for more than a year. The patient returned for follow up after a 14-month absence. He reported recurrent brief anxiety attacks after tapering the carbamazepine to 600 mg daily and starting paroxetine at 20 mg daily at the instruction of another physician. One attack was similar in severity to those described at the initial presentation. A repeated EEG failed to show epileptiform activities (Figures 2-3). He refused long-duration EEG recording using an epilepsy monitoring unit. His condition completely remitted for one year on 1200 mg carbamazepine daily and discontinuation of paroxetine.\nOUTPUT:" }, { "from": "agent", "value": "Temporal lobe epilepsy" } ]

[ { "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 34-year-old woman presented with new-onset ascites and worsening jaundice. A cholestatic liver profile demonstrated total bilirubin 17 mg/dL, direct bilirubin 10 mg/dL, aspartate aminotransferase 224 U/L, alanine aminotransferase 219 U/L, and alkaline phosphatase 822 international U/L. Ascitic fluid revealed a serum-ascites albumin gradient <1.1 g/dL. Fluid cytology was negative for malignancy, fluid cultures were negative, and fluid cell count was normal. She had presented to an outside small community facility 6 months prior with similar symptoms. Endoscopic retrograde cholangiopancreatography (ERCP) performed there revealed a common hepatic duct stricture with negative brush cytology. She underwent biliary stenting. Labs at our facility revealed an improved cholestatic liver profile with total bilirubin 11.9 mg/dL and alkaline phosphatase 614 IU/L. CA 19-9 was normal. A second ERCP with stent exchange was performed; however, biliary biopsies were not obtained due to previous negative cytology and the unavailability of an endoscopic ultrasound-guided cholangioscope (Figure 2). Repeat brush cytology was negative. Percutaneous biopsy of the psoas muscle revealed tumor cells expressing CCA-specific cytokeratin (CK) 7 and CK19 (Figure 3). Cystoscopy demonstrated trigonal fluffy tissue obscuring the left ureteral orifice, with pathology consistent with CCA. Based on a fluoroscopy image, the CCA was classified as Bismuth-Corlette type II. The patient's hospital course was complicated by hematemesis 2 months after the most recent ERCP. Esophagogastro-duodenoscopy showed a rigid stomach creating a challenging duodenal intubation (Figure 4).\nOUTPUT:" }, { "from": "agent", "value": "Cholangiocarcinoma, Linitis Plastica, Metastases to the Psoas Muscle and Urinary Bladder" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 58-year-old woman presented with acute loss of temperature and pain sensation in the left side of her body and in the left limbs following cervical pain. She visited our hospital 3 days after symptom onset. Her medical history included asthma, hyperlipidaemia and hypertension. Her daily medications were prednisolone (3 mg), alfacalcidol (0.5 mug), rupatadine fumarate (10 mg) and rosuvastatin calcium (2.5 mg). On physical examination, she was alert, well-oriented and afebrile with a blood pressure of 140/75 mmHg. She had lost temperature and pain sensation below the left C5 sensory level (Fig. 1A), while her sensations of touch, position and vibration were intact. She showed no symptoms of any cranial nerve abnormalities, muscle weakness, abnormal tendon reflexes, ataxia, Horner's syndrome or facial sensory loss. Her neurological symptoms were checked by two certificated neurologists. A blood test revealed normal blood profile with normal coagulation and thyroid, kidney and liver functions. Magnetic resonance imaging (MRI) findings revealed high-intensity signals in the right caudal lateral medulla oblongata on diffusion-weighted imaging (Fig. 1B and C), fluid-attenuated inversion recovery (Fig. 1D) and an enlarged right vertical artery (Fig. 1E). The MRI findings of the cervical spinal cord were normal. Consequently, we diagnosed her with LMI, suspecting right vertebral artery dissection as the aetiological cause. Therefore, we initiated clopidogrel administration (75 mg/day). Her sensory responses gradually improved from the left upper extremity on hospitalization day 3. Then, on hospitalization day 8, her sensory responses of the left lower extremity showed improvement. On hospitalization day 10, she was discharged to her home without any symptoms. At her 1-month follow-up examination, her neurological symptoms had improved substantially without stroke recurrence.\nOUTPUT:" }, { "from": "agent", "value": "Lateral medullary infarction" } ]

[ { "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 82-year-old woman presented with a recent history of dysphagia and heartburn. She underwent upper endoscopy which demonstrated a fungating mass extending 10 cm in length and protruding into and filling the lumen. The edges were necrotic and biopsies were obtained from the base of the lesion. Histology showed discohesive, small to medium sized cells, arranged primarily in solid nests, with focal necrosis (Figure 1). Cytologically, the cells showed scant to moderate amounts of cytoplasm and eccentric, irregular nuclei with prominent nucleoli. There was focal pagetoid involvement of the overlying squamous mucosa (Figure 2). Immunohistochemical stains were performed and the neoplastic cells were negative for cytokeratin AE1/AE3, cytokeratin cocktail, synaptophysin, chromogranin, p63, thyroid transcription factor 1 (TTF-1), leukocyte common antigen, and other lymphoid markers while they were diffusely positive for CD56. This immunophenotype excluded the possibility of squamous cell carcinoma. Then, stains for malignant melanoma were performed and demonstrated that the neoplastic cells were focally positive for S-100 protein while other MM markers including Melan-A and SOX10 were diffusely positive (Figure 3). Molecular testing did not reveal a V600E or V600K mutation in the BRAF oncogene or in the C-kit oncogene. A positron emission tomography (PET) scan was performed and highlighted the mass in the distal esophagus. It also revealed a 2 cm hypermetabolic liver lesion and hypermetabolic gastroesophageal lymph node (Figure 4). This PET scan also incidentally revealed bilateral hypermetabolic thyroid lesions. Chemotherapy was initiated with pembrolizumab, a monoclonal antibody that is given for metastatic or unresectable melanoma, but the patient's disease progressed with more extensive hepatic involvement by metastatic disease, and she died shortly thereafter.\nOUTPUT:" }, { "from": "agent", "value": "Primary esophageal melanoma with aberrant expression of CD56, Papillary thyroid 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: An 87-year-old man (Table 1) was admitted unconscious with HRF. This was his third admission for the same condition in 4 weeks. On each occasion, his blood gases were similar (Table 2). He was commenced on NIPPV and generally recovered consciousness later the same day. On awakening, he would panic and pull off the NIPPV mask and refuse to go on with the treatment. He would be observed for approximately 4 days and would remain hypercapnic (partial pressure of arterial carbon dioxide [PaCO2] >;6.8 kPa). Once judged clinically stable with optimized bronchodilatation, he would be discharged, only to return 1 week later unconscious in the same condition. On questioning, he denied any additional use of alcohol, sleeping tablets, tranquilizers, or painkillers prior to these episodes. He did not have home oxygen, and these episodes could not be explained by an infectious process. He had a home nebulizer (air driven) for salbutamol and ipratropium, a seretide 250 inhaler, frusemide, aspirin, digoxin, and oral theophylline. He was on mirtazapine 45 mg once daily (od) for his anxiety, and citalopram 40 mg od for several years without prior respiratory depression. He admitted to anxiety and panic disorders, even associated with using a nebulizer mask, and especially with the NIPPV mask. He felt that his respiratory condition had generally deteriorated over 6 months, following pneumonia the previous summer. He would not consider NIPPV even though the risks were explained. Low-flow nasal oxygen (1 L/min) rapidly increased the PaCO2 to >;8.3 kPa. To avoid a further admission and the risk of death, he was started on modafinil 200 mg in the morning. By 10 days of treatment, his arterial gases had improved, along with day- and nighttime oximetry (Table 2), and remained stable long-term. He had one admission with a myocardial infarction, without any respiratory concerns. Modafinil did not affect his previous anxiety, and he felt his breathing and well-being had improved. Lung function remained the same. In April 2013, he developed community-acquired pneumonia and died following admission, without HRF after 15 months of treatment.\nOUTPUT:" }, { "from": "agent", "value": "Hypercapnic Respiratory 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: CT showed a very large expansile lytic lesion involving the entire right sacral ala, eroding through the right SI joint and dorsal cortex, with accompanying visceral and other bony metastases. The lumbosacral spine was approached using a standard posterior midline exposure from L4 to the sacrum. The tumor was partially debulked and pedicle screws were inserted bilaterally at L4 and L5 (under fluoroscopic guidance). As the right S1 pedicle was destroyed, only a left S1 pedicle was inserted. Bilateral iliac bolts were inserted at the posterior superior iliac spine. Two rods were applied, and cross-connectors were used to connect the rods to the iliac bolts. Two cross-clamps were used to increase the strength of the construct. The orthopedic oncologist performed an intralesional excision followed by the percutaneous right SI screw placement. Crushed cancellous allograft and adult mesenchymal stem cell-based graft was applied lateral to the instrumentation over the SI joints and into the tumor defect. The patient sustained immediate pain relief, stayed 4 postoperative days, and was discharged home. The only complication was left iliac bolt irritation. At 82 postoperative weeks, the patient had occasional back pain, was on no pain medication, and ambulated without difficulty. The follow-up CT confirmed solid lumbar and iliolumbar fusion with partial SI fusion. Cases 2 and 3 are summarized in Table 1.\nOUTPUT:" }, { "from": "agent", "value": "Sacroiliac stabilization for sacral metastasis, Recurrent ovarian 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 53-year-old man was admitted to our hospital for further evaluation of anemia (haemoglobin concentration 10,6 g/dl, RBC 2.970.000/mm3, HTC 31,4%) associated to positive fecal occult blood test. He had neither bleeding from rectum nor diarrhea or other gastrointestinal symptoms. Abdominal examination was negative. Rectal exploration did not reveal any pathological sign. A colonoscopy identified the presence of a spherical, sessile, lobulated polyp of the cecum, 4.2 cm in diameter, with a red and not bleeding but partially ulcerated surface (figure 1). Because of the absence of a peduncle and its large size, the endoscopist decided to perform a biopsy of the polyp rather than a polypectomy. Considering the chronic anemia and the polyp's features (absence of a peduncle and size), we decided to perform an ileocecal resection with a latero-lateral ileocolic anastomosis (figure 2). There was not superficial fibrin exudation. The patient was discharged from our hospital four days after the operation without any postoperative complications. After two months the patient has good health and anemia was resolved.\nOUTPUT:" }, { "from": "agent", "value": "Inflammatory myoglandular polyp, Autoimmune haemolytic anemia, Autoimmune thyroiditis, Tubulovillous adenoma with low grade dysplasia" } ]

[ { "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 to another hospital in April 2013 because of one month history of dyspnoea and chest pain. A transthoracic echocardiogram showed a mass twisting between the right atrium and ventricle (Figure 2). With the suspicion of a malignant cardiac tumour, a cardiac catheter-guided endomyocardial biopsy was performed; the pathologic findings and immunophenotypic studies revealed a DLBCL. A complete blood count and serology was unremarkable; and also this patient was immunocompetent. PET/CT was not performed. The diagnosis was a PCL, and she was transferred to our institution in a critical condition. The patient was treated with a CHOP-like regimen: R-ACOD (Rituximab, Adriamycin, cyclophosphamide, vincristine, and prednisone) every 21 days for eight cycles. Based on our previous experience, we performed a lumbar puncture and a CT scan of the brain which were normal. Nevertheless, we decided to administer CNS prophylaxis with systemic HD-MTX at a dose of 1.5 g/m2 administered every two weeks for four cycles. After the first course of treatment, the patient noted an improvement in her cardiac symptoms. A transthoracic echocardiogram, cardiac MRI, CT scan, and PET/CT demonstrated complete disappearance of disease after four cycles of chemotherapy. One week later, the patient presented with headache and motor symptoms. The brain MRI showed two enhancing lesions surrounded by oedema, respectively located in the left frontal and frontoparietal regions (Figure 3). A lumbar puncture with flow cytometry of CSF was negative and systemic evaluation did not reveal any other location of lymphoma. She received induction chemotherapy with HD-MTX (3 g/m2 every two weeks for two cycles) for CNS relapse of lymphoma. However, the follow-up brain MRI after two courses of HD-MTX revealed progressive disease. Therefore, HD-MTX in combination with cytarabine was initiated as salvage therapy without improvement of CNS disease. Whole-brain radiotherapy was than performed with a CR. This patient was then consolidated with ASCT.\nOUTPUT:" }, { "from": "agent", "value": "Primary cardiac lymphoma, Isolated parenchymal central nervous system 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: A 43-year-old male underwent ultrasound examination of the abdominal cavity, which revealed a presence of well demarcated, hypoechogenic, somewhat heterogeneous solid mass, 9 cm in diameter (Figure 1). Power Doppler imaging showed no vascularization within the tumor. The diagnostics was extended to include contrast computed tomography of the abdomen and lesser pelvis, which confirmed the presence of a hypodense lesion in the retroperitoneal space (Figure 2). The lesion was not contrast-enhanced in the arterial or venous phases. Discrete, linear areas of contrast enhancement were visible in the late phase, about 10 min. after administration of contrast agent (Figure 3). Since malignancy could not be ruled out in CT images, a contrast MRI of the abdomen was also performed, revealing a solid tumor with regular margins adjacent to the upper pole of left kidney (Figures 4, 5). Tumor signal was homogeneously low in T1-weighted images, while T2-weighted sequences showed intermediate, heterogeneous signal. The tumor exhibited mild contrast enhancement, no diffusion restriction was noted in DWI sequences (Figure 6). Image was still ambiguous and the differential diagnosis included mild, slowly growing, solid tumor, an atypical cancer, and oncocytoma (without a typical central scar). No enlarged or pathological lymph nodes were visualized in any of the conducted imaging studies. The remaining abdominal structures were not pathologically changed. Routine blood tests showed no deviations from normal values. Erythrocytes were identified in the urine. Patient was referred for removal of the lesion and was admitted to the urology unit. It was revealed during tumor resection (operator: Wojciech Rogowski, MD) that the lesion was not connected to the kidney, but only adjacent to it and covered by a common capsule. Adrenals were unchanged. Tumor of the retroperitoneal tumor was removed as a whole and sent for histopathological examination (Figure 7). The tumor was composed of Schwann cells and mature ganglion cells. There were no features of nuclear atypia or necrotic foci.\nOUTPUT:" }, { "from": "agent", "value": "Ganglioneuroma" } ]

[ { "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 healthy boy presented to the emergency department with irritability for 3 days duration associated with fever of 39 C, nausea, anorexia, and vomiting. On examination, the child was irritable and pointing to the right lower area of the abdomen. The abdomen was distended and diffusely tender on palpation with localized rigidity at the right iliac fossa (RIF). Laboratory tests showed a white cell count of 24,300 cells/mm3 with a neutrophil predominance of 18,000 cells/mm3 and normal urine analysis. The patient underwent an emergent appendectomy. Intraoperatively, the distal omentum was found to surround a small area of the cecum with minimal necrosis seen at its surface which may represent a sealed small cecal perforation. Although the appendix was grossly normal, the surgeon had decided to perform an appendectomy. On postoperative day (POD) 3, the patient was discharged home though he came back due to irritability (Figure 3). An abdominal US showed echogenic fatty planes at RIF. At POD 6, another abdominal US showed mild to moderate intraabdominal fluids with echogenic fatty planes and multiple enlarged mesenteric lymph nodes at the RIF but with no evidence of collection. However, the patient's condition started to get better and was discharged home on POD 9.\nOUTPUT:" }, { "from": "agent", "value": "Appendicitis, Foreign Body in the Abdomen, Periappendicitis, Paralytic Ileus" } ]

[ { "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 non-throbbing occipitonuchal headaches which were worse on the right side. There was associated neck and shoulder pain on the right with paraesthesia and numbness of the right arm but no unilateral weakness, or objective loss of sensation. She experienced transient dysphagia. She had no tinnitus, hearing impairment, or otalgia. She was discovered to be hypertensive 4-years before presentation. She was an obese, middle-aged woman with BMI of 32.6 kg/m2. She otherwise had no focal signs on neurological examination. She had thickened arterial walls with blood pressure of 140/110 mmHg. She was on Moduretic half tablet daily and enalapril 5 mg daily. Her blood sugar and fasting lipid profile were normal. Doppler ultrasound of the vertebral arteries showed that the right vertebral artery was tortuous with mildly elevated velocities (Table 1). She wore the collar constantly and did not report any muscle spasm.\nOUTPUT:" }, { "from": "agent", "value": "Episodic vertigo, vascular risk factors, cervical spondylosis, hypertensive heart 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: The depression of chest wall had been noticed when he was 10 and progressed in the past years. He complained of unsatisfied appearance and occasional shortness of breath upon exertion, but no chest pain or palpitations. On physical examination, a sunken sternum was noted. 1A). Pulmonary function tests were within normal limits. The patient underwent a Nuss procedure (Fig. 1B). After general anesthesia, 2 small incisions were made bilaterally at the mid-axillary line of the chest. Then an introducer was pushed through the skin incision to create a substernal tunnel. A bent metal bar was slipped under the sternum under the guidance of a thoracoscope. Once placed in an appropriate position, the bar was flipped 180 degrees and elevated the depression as expected. Stabilizers and wires were used to fix the bar to the ribs. The surgery was completed successfully and the recovery process was uneventful. Four weeks postoperatively, the patient was noted to have an asymmetric back and referred to an orthopedic surgeon. Whole spine X-ray showed a right-sided thoracic curve ranging from T3 to L4 with a Cobb angle of 54 degrees (Figs. 1C and 2A). Chest CT revealed a Haller index measuring 3.02 postoperatively. Full spine radiograph demonstrated that the curve magnitude decreased from 54 to 41 degrees (Fig. 1D). Moreover, we prescribed the patient to wear a customized Boston-type orthosis for 12 h per day (Figs. 1E and 2B). Three months later, the curve disappeared (Figs. 1F and 2C).\nOUTPUT:" }, { "from": "agent", "value": "Acquired scoliosis, Pectus excavatum" } ]

[ { "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 male, chronic alcohol consumer, presented with progressively increasing dysphagia of 6 months duration. There was history of loss of weight. He was a known diabetic with blood sugar well controlled with oral drugs. However, after onset of dysphagia, his blood sugar control was erratic and had frequent episodes of hypoglycemia. Clinical examination revealed hepatomegaly. Laboratory examination revealed hypoalbuminemia with mildly elevated liver enzymes. Upper gastrointestinal endoscopy revealed dilated esophagus with residue. 1). A contrast-enhanced computed tomography of chest and abdomen revealed dilated esophagus enlarged liver with irregular outline and intra-abdominal collaterals. 3). Patient was started on calcium channel blockers with no relief of symptoms. What to do next? 4). Following this, the patient had marked improvement in his symptoms and was completely free of dysphagia 7 days later and also blood sugar was controlled with oral drugs. He is asymptomatic till the last follow up 3 months after injection.\nOUTPUT:" }, { "from": "agent", "value": "Achalasia cardia, Esophageal varices, Diabetes, Chronic liver disease, Portal hypertension" } ]

[ { "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 male presented with complain of a slowly growing conical asymptomatic lesion at the left angle of mouth. The lesion had been present for the past 2 years and was gradually increasing in size despite the patient having cut off its tip several times. History of cigarette smoking for the past 30 years was present. Past medical history was insignificant. On examination, a hard, grey coloured, conical keratinized lesion measuring 3 x 1 cm was present over the left angle of mouth (Figure 1). Neck examination was suggestive of levels I and II cervical lymphadenopathy on the left side. Preoperative work-up included routine blood investigations and X-ray chest which were within normal limits. FNAC from neck node was inconclusive. Primary closure of the defect was done in 3 layers. Postoperative period was uneventful and patient was discharged on postoperative day 5. All neck nodes were free of tumor. No clinical relapses were detected after 2 years of follow-up.\nOUTPUT:" }, { "from": "agent", "value": "Carcinoma buccal mucosa, Giant cutaneous horn" } ]

[ { "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 X-ray at the time of initial presentation showed an osteolytic lesion in the distal femur meta-epiphysis complicated by an intra-articular pathological fracture, for which external fixation was performed (Figure 2(a)). Cortical scalloping was present on CT and no matrix formation was noted (Figures 2(b) and 2(c)). MRI showed a high signal intensity on T1-weighted images, partly due to hemorrhage after the fracture. T2-weighted images showed a heterogeneous mass with mostly high signal intensity. A posterior soft tissue mass was found and intra-articular extension of the tumor was present anterolaterally (MR images not shown, due to poor quality). Biopsy confirmed the diagnosis of conventional GCTB (Figures 2(d)-2(f)). The patient was treated with curettage and cement and the fracture was fixated with plate osteosynthesis. On a follow-up CT of the knee performed 1 year later, new osteolysis was present medial of the cement with cortex destruction, interpreted as a local recurrence (Figure 3(a)). The patient was therefore started on denosumab treatment. After 10 months on denosumab, the CT showed progression into a large medial soft tissue mass which was covered by irregular neocortex. The bone density of the endomedullary component of the local recurrence was increased most likely due to denosumab. However, within the increased soft tissue mass there was new osteoid matrix formation proximally, suspicious of malignant transformation in GCTB (Figure 3(b)). En bloc resection was performed, the macroscopic resection specimen (Figure 3(c)) and preoperative sagittal CT reformatted image (Figure 3(d)) showed corresponding endomedullary fibro-osseous matrix formation (asterisk) with osteoid deposition in a posteromedial new mass lesion. Histology at the time of en bloc resection revealed a sarcomatous appearing cellular spindle cell proliferation with areas of tumor necrosis and the formation of tumor osteoid. The endomedullary osteoid deposition was more regular in appearance and the criteria for sarcomatous progression were not met. Therefore this fitted with denosumab induced changes.\nOUTPUT:" }, { "from": "agent", "value": "Malignant Transformation of Giant Cell Tumor of Bone, High-grade osteosarcoma" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: The patient is a Caucasian female born at term with a birth weight of 3.06 kg; pregnancy and delivery were uncomplicated. She had a three month history of progressive Cushingoid facies, acne and irritability. Her linear growth apparently had been arrested between three and six months of age, although she gained weight at an accelerated rate (Figure 1). Prior to referral, laboratory evaluation by her primary care physician revealed serum cortisol of 240 mcg/dl (normal, 4.5-22.7 mcg/dl); total testosterone of 185 ng/dl (normal, 6-77ng/dl), and DHEA-S of 401 mcg/dl (normal, 16-96 mcg/dl). Serum ACTH was less than 5 pg/ml (normal, 10-60 pg/ml). Her weight at initial evaluation in our clinic at six months of age was 7.52 kg (60-75th percentile) and length was 59.1 cm (<5th percentile). Blood pressure was 110/70 mmHg. Physical examination showed Cushingoid facies, buffalo hump, facial acne, and poor muscle tone (Figure 2). There were no signs of virilization. Family history was noncontributory. An MRI of the abdomen showed a heterogeneous right adrenal mass measuring 3.6 x 5.4 x 3.8 cm; this mass was found to extend as a tumor thrombus into the inferior vena cava. The tumor thrombus appeared to extend to approximately 2 cm from the right atrium. There were no metastases seen in the liver or lungs on MRI. A Doppler ultrasound showed minimal, but present flow around the IVC tumor thrombus which measured 2.5 x 0.9 x 1 cm. Laboratory evaluation showed serum cortisol 70.8 mcg/dl (normal, 4.5-22.7 mcg/dl); aldosterone 4.2 ng/dl (normal 6.5-86.0 ng/dl); testosterone 59 ng/dl (normal, 6-77 ng/dl); ACTH <5 (normal, 10-60 pg/ml).\nOUTPUT:" }, { "from": "agent", "value": "Cushing Syndrome due to Adrenocortical Tumor" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: Mr A was a 54-year-old male who had been diagnosed as having chronic schizophrenia, paranoid type. The initial presentation of his psychosis consisted of auditory hallucination and delusions of persecution. He was hospitalized in the chronic ward of a mental institute. He had no previous physical illness history. The baseline laboratory data when hospitalized revealed no significant abnormality, and the routine chest X-ray and electrocardiography showed no significant finding. He had received clozapine 200 mg/day for 2 years without discomfort or drug side effects. Two weeks before the event of SJS, he developed acute gastroenteritis with nausea and vomiting, and recovered from it spontaneously. However, he developed an acute onset of mouth edema, oral and ocular multiple ulcers, injected oral and ocular mucosa, and multiple erythematous skin rashes over his entire body and extremities. When the event of SJS came, he only took clozapine 200 mg daily without any other concomitant drugs. His vital signs revealed hypertension, 153/101, with a high fever of 39.1 C. Because of the emergent condition, he was soon referred to a general hospital for intensive care, where SJS was diagnosed. The laboratory data at that time revealed acute inflammation with elevated C-reactive protein (143.2 mg/L) and leukocytosis (1.47x104/muL). There was not any acute renal or hepatic failure noted. After supportive treatment, his critical condition subsided and he returned to our hospital 1 month later. The follow-up laboratory data 1 month later revealed gradually improved leukocytosis. His psychotic symptoms were well controlled under risperidone 3 mg/day, which was prescribed after this event subsided. He did not have any obvious drug side effects under risperidone treatment.\nOUTPUT:" }, { "from": "agent", "value": "Stevens-Johnson 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 34-year-old woman who had undergone bilateral LASIK one month earlier at another eye clinic was referred to our hospital complaining of blurred vision and pain in the left eye. Other ophthalmic examination findings were unremarkable. Corneal scrapings were taken, but the results were negative. The patient was treated topically with hourly instillation of 0.3% micronomicin, 0.5% levofloxacin, and 0.5% cefmenoxime, together with systemic administration of imipenem (2 g/day). Since the health care center disclosed that nontuberculous mycobacterium was detected on the surgical instruments, including the microkeratomes, we then added oral clarithromycin (400 mg/day), and substituted systemic administration of amikacin (400 mg/day) with that of imipenem as the treatment regimen. No complications (such as iatrogenic keratectasia or recurrent infection) occurred during the three-month observation period.\nOUTPUT:" }, { "from": "agent", "value": "Infectious keratitis, Flap necrosis" } ]

[ { "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 double-blind, placebo-controlled, age-descending, dose-finding trial was undertaken in 40 adults, 60 children aged 10-23 months and 146 aged 6-9 months old (; PACTR201905764389804). Adults received a single full dose of ETVAX and children received 3 doses of either 1/4 or 1/8 of the vaccine. All vaccine doses also included 2.5 ug of dmLT. There were no differences in the frequency of solicited or unsolicited adverse events between vaccine recipients receiving 1/4 and 1/8 dose and no increase in frequency or severity of systemic reactogenicity with increasing number of vaccinations or decreasing age. The vaccine induced plasma IgA and IgG responses against LTB in 100% of the adults and 80-90% of the children. In children aged 6-9 months, IgA response rates against >= 4 vaccine antigens after 3 doses determined as >= 2-fold and >= 4-fold rises were significantly higher for 1/4 dose compared to placebo (65.1% vs 27.6%, p=0.004 and 32.6% vs 6.9%, p=0.01, respectively). The Zambian studies further demonstrated that ETVAX was safe, tolerable, and immunogenic in adults and children. Using 3 doses, the maximum expected number of doses to be used in children in LMICs, the 1/4 dose was again shown to be safe and induced significant IgA responses in children. Evaluation of pre-and post-vaccination plasma samples from 20 children aged 10-23 months was accomplished using a proteome microarray. Post-vaccination, reactivity to CFA/1, CS3, CS6, and LTB was stronger than baseline among the vaccinated compared to the placebo group. The CS5 protein was not included in the microarray. Three other purified non-vaccine ETEC proteins; CS4, CS14, and PCF071 had significantly higher post-vaccination responses. These data suggest that ETVAX induces cross-reactive IgG antibody responses to non-vaccine CFs CS4, CS14, and PCF071 from the class 5 fimbriae. This activity could provide some broad IgG antibody coverage beyond the core vaccine antigens (CFA/I, CS3,CS5, CS6 and LTB) themselves. Field evidence that effective immunization with ETVAX can be protective in man.\nOUTPUT:" }, { "from": "agent", "value": "No specific diagnosis" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A man with a history of smoking 20 cigarettes per day, hypercholesterolemia and arterial hypertension was admitted to our center for diagnostic evaluation of recurrent episodes of angina. Past medical history was significant due to MS, which had been diagnosed four years prior to admission by extensive neurological investigation following the development of paresthesia on the left frontal side of the head. Magnetic resonance imaging (MRI) of the brain showed numerous ovoid and confluent hyperintense lesions in the white matter of periventricular and subcortical areas and basal nuclei, with few areas of enhancement interpreted as active lesions. MS was diagnosed, and he was initially treated with high-dose interferon ss. In the following years, the disease showed relapsing-remitting characteristics, with occurrence of spastic paraparesis of the four limbs and of inter-nuclear ophthalmoplegia with horizontal diplopia. On admission a dobutamine stress echocardiogram resulted positive for inducible angina. Coronary angiography showed intra-stent stenosis of the right coronary artery and critical stenosis of the proximal left descending coronary artery. Trans-thoracic echocardiography showed no cardiac valvulopathy, and preserved left ventricular ejection fraction.\nOUTPUT:" }, { "from": "agent", "value": "Multiple Sclerosis, Inferior Myocardial Infarction, Hepatic Steatosis, Manic 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: A 68-year-old man underwent penetrating keratoplasty for aphakic bullous keratopathy and corneal scarring. He had no history of herpetic disease. The donor cornea originated from a 71-year-old female who died due to chronic pulmonary disease. The time interval between death and transfer of the corneoscleral button into organ culture medium was 36 h. The endothelial count was 2400cell/mm2 with mild polymegethism and pleomorphism. A 8.5 mm Hessberg-Barron trephine was used to prepare the donor cornea and a 8 mm trephine for the recipient. After placement of the donor onto the aphakic eye a large dendritic-geographic epithelial ulcer was noted (Fig. 1). The graft was removed, all surgical instruments were changed and the surgical staff regowned. Fortunately, a second donor corneoscleral disc was available, which was then used to complete the operation instead of resuturing the patient's own cornea back into place. The second donor originated from a 69-year-old male who died from a myocardial infarction. The time interval between death and transfer of the corneoscleral button into organ culture medium was 40 h. The endothelial count was 2600cell/mm2 with some variation in cell size and shape. Perioperative intravenous aciclovir was administered intravenously (5 mg/kg). Postoperatively, the patient was commenced on systemic and local antiviral therapy for 1 week (valaciclovir 1 g three times a day, acyclovir ointment five times per day) and local antibiotic treatment (chloramphenicol four times a day). Topical steroids were withheld for 48 h. At 1 week the graft was clear and had re-epithelialized. Long term prophylactic acyclovir 400 mg twice a day was commenced but 6 months later the patient developed a geographic corneal ulcer involving the graft-host interface (Fig. 2) with keratic precipitates and corneal oedema (central corneal thickness 710 mum). The patient was treated with acyclovir 400 mg and topical aciclovir both five times a day for 2 weeks with resolution of the ulcer and residual scarring.\nOUTPUT:" }, { "from": "agent", "value": "HSV-1 keratitis" } ]

[ { "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: Moreover, the free radicals found in inhalable aerosols of ENDS may have a similar effect. Mechanisms for the relationship between cigarette use and nutrient status fall under 2 categories: behavioral and physiological. Behavioral mechanisms are hypothesized to remain consistent across 2 categories of tobacco users: ENDS users and combustible cigarette users may consume less-nutrient-dense diets. Physiologically, however, there may be differences between ENDS and combustible cigarettes.\nOUTPUT:" }, { "from": "agent", "value": "Folate deficiency" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: The authors present a case of a 72-year-old male, with a past medical history of diabetes mellitus and arterial hypertension, who was admitted to the emergency department due to fever and diarrhoea with 4-day evolution. On the physical evaluation, the patient was hypotensive (blood pressure of 84/44 mmHg) and dehydrated, without any other significant findings. Blood analysis revealed leucocytosis (12,200/mm3) with neutrophilia (10,800/mm3), elevated C-reactive protein (9.5 mg/dl) and an acute kidney injury (creatinine 7.34 mg/dl). Due to haemodynamic instability, the patient needed aminergic support and renal replacement therapy. The patient was treated with ciprofloxacin, in accordance with bacterial antibiotic susceptibility tests. With a positive clinical evolution he was discharged after completing antibiotic treatment, clinically asymptomatic. Three weeks after discharge, the patient was evaluated on a follow-up consult and complained of testicular pain and weight loss of 5 kg over the previous 15 days. On the physical evaluation, he presented multiple purpuric lesions with ulcers, pustules and necrotic tissue on his legs (Figs. 1 and 2) and petechiae on his arms. A cutaneous biopsy was performed, showing areas with detachment of the corneal layer with keratinocyte necrosis and abundant polymorphonuclear cells (Fig. 3) and polymorphonuclear infiltration of the arteries of the deep dermis and hypodermis with focal signs of vasculitis (Fig. The patient was treated with prednisolone, starting with 60 mg followed by progressive dose reduction, with complete remission of the skin lesions.\nOUTPUT:" }, { "from": "agent", "value": "Salmonella Infection, Polyarteritis Nodosa" } ]

[ { "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 a massive tumor of upper extremity for which a wide local excision was done. Radiation therapy was performed within less than one month following surgery which lasted for about 5 weeks. Firstly, the dehiscence was tried to be managed by clean wet dressings for about 2 weeks. However, due to lack of response he was treated with PRP gel (Fig. 1A, 1B). The patient's wound responded dramatically and healed in two weeks (Fig. 2A, 2B). During the last two decades, there was a burst through PRP therapy in tissue repair. A variety of potentially therapeutic growth factors were detected and released from the platelets in significant levels in platelet-rich plasma preparations. Release of these growth factors into the site of wound injuries could expedite wound healing. [3] The very first application of PRP was in the field of musculoskeletal system. [1,4] McAleer et al have also reported their experience with concentrated autologous platelet-derived growth factors in healing of chronic lower-extremity wounds which was evaluated in 24 patients with 33 lower-extremity wounds. [5] Wound closure and complete epithelialization was achieved in 20 wounds. [6] Villela et al carried out a systematic review in 2008 and found five studies on ulcers of diabetic etiology. The results of meta-analysis showed that PRP had positive effects on the healing process (95% CI: 2.94-20.31). PRP thus may be tried in such conditions. Source of Support: Nil\nConflict of Interest: None declared\nOUTPUT:" }, { "from": "agent", "value": "Soft tissue sarcoma of the extremity, Dehiscence of surgical wound" } ]

[ { "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 with no systemic comorbidities presented with sudden, painless diminution of vision in the left eye 4 months back. There was no relevant family history or past history of thrombotic episodes. Best-corrected visual acuity was 20/400 in the left eye and 20/20 in the right eye. A relative afferent pupillary defect was present and the rest of the anterior segment examination was unremarkable. The gonioscopic examination was normal with an intraocular pressure of 16 mmHg recorded bilaterally on Goldmann applanation tonometry. Fundus revealed elevated, nonhyperemic optic disc which was more conspicuous nasally. Blurred disc margins, moderate venous tortuosity, peripapillary hemorrhages, vascular sheathing, and macular edema were seen, consistent with resolving CRVO [Figure 1]. There was no evidence of vasculitis. The right eye examination was unremarkable. Fundus fluorescein angiography (FFA) showed a delay in arteriovenous transit time, venous wall staining, petaloid leak at the macula, late peripapillary leak, and staining of the optic disc [Figure 2]. Spectral-domain optical coherence tomography (SD-OCT) showed atrophy of inner retinal layers and intraretinal hyporeflective cystoid spaces at the macula [Figure 3a]. Tomography of ONH demonstrated increased peripapillary retinal nerve fiber layer thickness suggesting disc edema [Figure 3b and c]. Blood pressure was recorded to be 130/80 mmHg. A battery of investigations for vascular risk factors including complete hemogram, erythrocyte sedimentation rate, blood glucose, cholesterol, immunoglobulin levels, C-reactive protein, protein C and S assay, antithrombin III assay, homocysteine, factor V, antinuclear antibody, anticardiolipin antibody, and antiphospholipid antibody titer were within normal limits. The persistence of severe disc elevation after 4 months of onset, especially conspicuous on the nasal aspect of the optic disc, and the presence of peripapillary hemorrhages aroused the suspicion of an occult etiology. US examination of the right eye was unremarkable.\nOUTPUT:" }, { "from": "agent", "value": "Unilateral buried optic nerve head drusen, Central retinal vein occlusion" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 62-year-old man with RA for >=10 years who presented with abdominal bloating was hospitalized. He was receiving MTX (10 mg/week), iguratimod and bucillamine, and he showed no evidence of viral hepatitis, diabetes mellitus or alcoholism. His aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels were 79 and 53 U/l, respectively. His platelet count was 50x103/microl. The fibrosis 4 (FIB-4) score, {[Age (year) x AST (U/l)] / (platelet (x103/microl) x ALT (U/l))}, was 13.46 (advanced liver fibrosis). 1a and b: 7 and 3 years before hospitalization, respectively). 1c). Then, MTX treatment was discontinuated. Ten months after drug discontinuation, his AST and ALT levels reduced to 25 and 20 U/l, respectively, and the platelet count and FIB-4 score were 109x103/microl and 3.23 (moderate liver fibrosis), respectively. 1d). Among all types of MTX-induced liver damage, liver cirrhosis is rare. To our knowledge, there are no reports of radiological changes in the liver and ascites in RA patients receiving MTX. Disclosure statement : The authors have declared no conflicts of interest.\nOUTPUT:" }, { "from": "agent", "value": "Methotrexate-associated reversible liver atrophy, Rheumatoid arthritis" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 23-year-old man presented in 2011 with increasing abdominal pain. In October 2011, he developed obstructive symptoms and underwent exploratory laparotomy. It was consistent with a pT4 pN2 (4/28) pM1 adenocarcinoma, K-RAS wild type. From January to July 2012, he received 12 cycles of FOLFIRI plus bevacizumab at another institution and had complete clinical response. Therefore, it was decided to stop his chemotherapy completely. In September 2013, he again developed abdominal pain. A PET-CT scan revealed FDG-uptaking lesions in the peritoneum as well as in the colonic anastomosis. From June 2014 to June 2015, he received 24 cycles of FOLFIRI and cetuximab with initial response followed by stable disease. In September 2015, he was first seen at our institution, and during a multidisciplinary meeting, it was decided to pursue CRS with HIPEC (oxali-platin 300 mg/m2), which occurred on October 5, 2015. He stayed at the ICU for only 72 h, and had the first bowel movement 6 days after surgery. On the 7th postoperative day, he developed fever with no identified origin, and was started on piperacillin-tazobactam and vancomycin. At this time, the patient was also complaining of left scrotal pain and swelling. An ultrasound of the testis was performed on October 17th and showed normal testicles and increased volume of the left epididymis with heterogeneous echogenicity. 1). The patient was discharged home on October 22, 2015, to complete antibiotics at the outpatient unit. As of November 23, the patient was still facing left scrotal discomfort, although less in intensity.\nOUTPUT:" }, { "from": "agent", "value": "Acute epididymitis, Adenocarcinoma of the transverse colon" } ]

[ { "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 two-month-old baby girl presented with painless and non-itchy erythematous papules as well as hyperpigmented macules and papules in almost all parts of the body except the face, both palms and feet (Figure 2A and B). From history taking revealed that the skin lesions appeared since birth in the form of erythematous papules and vesicles on both arms, which continuously increased in number and spread all over the body. Some of the erythematous papules and vesicles resolved and formed verrucous papules (Figure 2C-E) and also hyperpigmented macules (Figure 2F and G), whereas new lesions kept appearing. There was no family history with the same complaint. On physical examination, on almost all parts of the body except the face, both palms and feet, there were erythematous macules and papules, vesicles, verrucous papules and also hyperpigmented papules, distributed linearly and swirled along Blaschko's lines. Linear skin lesions in the form of atrophic striae were found on the medial side of the upper right thigh. Laboratory examination results showed eosinophilia (27%). Based on the clinical features, we diagnosed this patient was IP with vesicular phase overlapped with hyperpigmentation and atrophy phases. No abnormalities were found in the EEG, whereas ophthalmological evaluation by the ophthalmologist showed RN on the peripheral side of the left eye. Histopathological examination with routine hematoxylin eosin stains indicated IP features. The patient was given with a moisturizer and 0.1% mometasone furoate cream to be applied on erythematous papules. On day 140 of evaluation, the skin lesions resolved, leaving hyperpigmented macular lesions, and the RN achieved spontaneous resolution.\nOUTPUT:" }, { "from": "agent", "value": "Incontinentia Pigmenti, Retinal Neovascularization" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 78-year-old man presented to a primary care unit with epistaxis from the left nasal cavity. Two days later, the patient was admitted to the emergency department of our hospital in respiratory distress with tachypnea and tachycardia. His initial vital signs included a blood pressure of 173/98 mmHg, a pulse of 117 beats per minute, a respiratory rate of 26 breaths per minute, and oxygen saturation of 86% on room air. Examination of the respiratory system revealed absent breath sounds over the right hemithorax, with a dull sound during percussion. The chest X-ray demonstrated atelectasis of the right lung and retraction of the mediastinum to the right. Although no episode of choking or intense cough was witnessed by the patient's family during the last 2 days, a suspicion for foreign body aspiration arose because of the missing gauze pack. For this reason, the patient underwent rigid bronchoscopy under general anesthesia, and during the procedure, a foreign body was found to obstruct the right main bronchus. The foreign body, which consisted of the missing gauze pack saturated with mucus and blood clots, was removed successfully. Due to his critical state, the patient was transferred intubated to the intensive care unit, where his respiratory function improved considerably, and intravenous antibiotics were also administered. The patient recovered completely and was discharged after 12 days of hospitalization.\nOUTPUT:" }, { "from": "agent", "value": "Nasal packing aspiration, Alzheimer's disease" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: An 18-year-old woman presented with excruciating right periumbilical colicky pain, preceded by an episode of vomiting. On physical examination, muscle guarding with rebound tenderness was elicited at right iliac fossa. Preoperative complete blood count yielded neutrophilia and mild eosinophilia. Grossly, the appendix appeared inflamed. On a cut section, the dilated lumen contained only mucoid debris. Histopathologically, the appendix was found to be infiltrated transmurally up to its serosa with many inflammatory cells, including eosinophils, and the mucosa was focally ulcerated. Its lumen contained scant necroproteinaceous exudate. Within that debris, a distorted but yet viable brood capsule of the Echinococcus species was recognized. It was a vesicle-like structure, filled with a thin proteinaceous fluid and sheathed by a thick acellular cuticular membrane. The capsule contained a single central protoscolex, with three distinct parts: the broad globular scolex, the soma or body, and a constricted part in between known as the neck. In similar conditions, some patients may present with hypersensitivity-like symptoms in response to immunogenic hydatid fluid leakage, but our patient did not report such symptoms. Her liver function test was within normal limits. She was promptly instituted upon oral albendazole (800 mg daily for 3 months). The patient was free of relapse at a 7-month follow-up visit.\nOUTPUT:" }, { "from": "agent", "value": "Acute Appendicitis, Asymptomatic Hepatic Hydatid 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: Case 2 is a 66-year-old female, presenting with general illness, fever (40 C), and hypotension. Prior medical history included beta-blocker therapy for tachyarrhythmia, appendectomy, colon cancer, and splenectomy for colonic metastases. On admission, she exhibited skin ischemic lesions with rapid deterioration to whole body cyanosis and metabolic and lactic acidosis. Empirical antibiotic therapy started with ceftriaxone (2 g every 12h) and levofloxacin (500 mg every 12h). Empirical antibiotic therapy continued for 11 and 7 days, respectively, with adjustments due to renal function changes. In the further course, she became oligoanuric, severely hypotonic with hemodynamic instability (epinephrine 0.4 mug/kg/min), and thrombocytopenic, presenting severe bleeding. A CVVHDF treatment (Multifiltrate, AV1000, Fresenius Medical Care, Germany) was started in combination with one 24-hour session of Cytosorb hemoadsorption immediately after the ICU admission. This combined treatment resulted in a clear and progressive hemodynamic stabilization accompanied by a marked reduction of epinephrine to 0.1 mug/kg/min (Figure 1) and a reduction of CRP, from 17.5 mg/dl to 13 mg/dl. Lactacidemia, elevated at the admission (15 mmol/l), decreased until 4 in the first 24h. At the same time, PCT decreased from 18.35 ng/ml to 2 ng/ml after 6 days (Figure 2). Subsequent to this first acute event, the patient showed a recrudescence of the septic state. Because of her severe injuries at the extremities, the patient needed amputations and 2 months later, the reoccurrence of the second septic episode caused the death of the patient.\nOUTPUT:" }, { "from": "agent", "value": "Pneumococcal and Meningococcal Sepsis, Severe Purpura Fulminans, Sepsis-associated tubular necrosis, Enterobacter aerogenes 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: In August 2012, a 67-year-old Japanese woman was admitted to our hospital for an evaluation of severe pain in the bilateral ankles to distal tibiae, knee joints, and ribs. Hepatitis due to HBV infection was diagnosed in 1983. Lamivudine was started in 2006, but her hepatitis did not subside, so low-dose ADV was added (10 mg daily) in March 2008. Two months later, the HBV-DNA polymerase titer became negative. In June 2012, generalized bone pain suddenly occurred without any precipitating cause and then worsened. On admission, the patient was 158 cm tall and weighed 63.8 kg. The laboratory data are shown in Table 1. Potential causative disorders such as multiple myeloma were excluded. Radiographs of the lower tibial shaft showed narrow radiolucent lines measuring 2 to 4 mm in width with sclerotic borders, which are called Looser zones and indicate the presence of pseudofractures. These were more prominent in the right leg (Fig. 1a). Bone scintigraphy with 99mTc-labeled methylene diphosphonate (MDP) demonstrated a high uptake in the bilateral ankles to distal tibiae (including the pseudofractures of the lower tibial shaft), knees, and ribs (Fig. 1b). When the bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry (DEXA), the right forearm and right hip had a BMD that was 2.0 and 2.4 SD below the female mean peak bone mass (T-score), respectively. The serum p level became less than 2.0 mg/dL at 20 months after the administration of ADV, while bone pain occurred at 52 months, and bone biopsy was done at 56 months (Fig. 1c).\nOUTPUT:" }, { "from": "agent", "value": "Osteomalacia Related to Low-dose Adefovir, Fanconi 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: This case highlights the importance of whole genome sequencing in such cases for proper diagnosis. In another case report, a 3 month old infant was found dead while sleeping and postmortem CT scan showed fatty attenuation in the liver parenchyma. Matrix assisted laser desorption/ionization imaging mass spectrometry (MALDI-IMS) analysis was conducted to further investigate the underlying mechanism of lipid accumulation. Genetic analysis showed two novel mutations in ACADVL gene. In a recent study, brain, heart, liver and kidney weights of SIDS victims were compared to controls. There was a large samples size of 291 SIDS and 294 controls obtained from Australia and Russia. Brain, thymus, liver and body weights were significantly higher among SIDS as compared to controls. Heart weight was significantly less in SIDS cases. Major difference was observed among thymus and brain weights and sizes. Heavier thymus points out to a possible infectious link to SIDS demises and larger brain sizes and weights shows a possible neuropathological roles. Larger thymus highlights the possible involvement of immunological genes which may be explored in this context. Genes related to neurotransmitters, their receptors and cardiopulmonary system should also be investigated further. Larger livers show a possible role of biochemical parameters and fatty acids and need to be studied in detail. In another study, the frequency of extramedullary haematopoiesis (EMH) was observed to be significantly higher in SIDS victims as compared to controls which may be due to anemia associated with intrauterine hypoxia or infections.\nOUTPUT:" }, { "from": "agent", "value": "Bartter's syndrome Type III, very long-chain acyl-CoA dehydrogenase (VLCAD) deficiency, Sudden Infant Death 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: The patient's last eye exam had almost been 10 years earlier, and there was no documentation of iris abnormality. The patient himself did not notice if anything was wrong with the eye. His past social history revealed alcohol and cocaine use. The infection work-up including syphilis was negative. On exam, vision was 20/60 in the right eye and 20/50 in the left eye. Loose iris strands were noted on both eyes, predominantly the left eye. Bilateral cataracts were noticed with narrowing of the angles. Intraocular pressures were normal. On gonioscopic exam, the angle was obscured by iris strands in one quadrant, the rest of the angle seemed narrow. This was confirmed by anterior segment OCT (Zeiss Meditech) (Figure 1 (Fig. 1)). The patient was offered to have cataract surgery in his worse seeing eye first. However, he missed multiple appointments, and when he presented one year later, his vision was reduced to bare light perception in the right eye and 20/150 in the left eye, with IOP measuring 45 mm Hg in the right eye and 12 mm Hg in the left eye. The angle was completely closed in the right eye with a large mature cataract. This time, further iris splitting was noted in addition to visible iris vessels on the right (Figure 2 (Fig. 2)). Advanced nuclear sclerosis and posterior subcapsular cataract were noted on the left eye as well. This time, the patient agreed to cataract surgery on the left eye only. Axial length was shorter than normal, 22.41 mm and 22.49 mm, right and left eye, respectively. The patient underwent successful cataract surgery on the left eye. Vision improved to 20/20 within one month of surgery. The iris strands obtained during the cataract surgery were sent for a pathologic exam. No atypia, inflammation, or reactive changes were found in the specimen.\nOUTPUT:" }, { "from": "agent", "value": "Iridoschisis, Metastatic Melanoma, Skin Basal 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 62-year-old postmenopausal married woman presented with slow-growing extremely pruritic plaque on the perineal skin. It initially started as a small pruritic papule which enlarged gradually to the present size in 3 years. There was no history of bowel or bladder disturbances. There was no history of sexually transmitted infection and diabetes mellitus. On the basis of clinical presentation, she was diagnosed as a case of lichen simplex chronicus and started on topical medications and antihistamines. There was no response to any topical/systemic steroids, antibiotics, and antifungals. General and systemic examination revealed no abnormality. Dermatological examination revealed approximately a 7 x 8 cm well-marginated, hypertrophic, and verrucous plaque in the perineal region. [Figure 1] At places grayish crusts with shallow erosions and a purulent discharge was seen. [Figure 2] There was no similar lesion anywhere else on the body. Proctoscopy examination was within normal limits. There was no regional lymphadenopathy. A part of the plaque was excised for histopathological evaluation. Hematoxylin and eosin staining of the biopsy from the lesion showed large round cells with ample pale-staining cytoplasm, pleomorphic nuclei, and occasional prominent nucleoli, indicative of Paget cells. Inflammatory infiltrate with invasion of Paget's cells into the dermis at places was seen [Figure 3]. Cells were positive for PAS lying singly and in clusters also seen infiltrating along the skin appendages [Figure 4]. Gynaecological examination and mammography was normal. Laboratory investigations were normal. Ultrasonography of abdomen-pelvis, Magnetic resonance imaging and computerized tomography scan of the abdomen did not reveal any intraabdominal mass or retroperitoneal lymph nodes. Hence, there was no evidence of visceral malignancy. The patient was then referred to an oncosurgeon who performed a surgical excision considering the premalignant potential of the disease. The patient followed up 1 month after the surgery with no recurrence and lymphadenopathy. She was lost for follow-up later.\nOUTPUT:" }, { "from": "agent", "value": "Extra Mammary 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: A single chamber ICD was recommended as a primary prevention against sudden cardiac death. After informed consent vascular access was obtained using modified seldinger technique and right ventricular lead was placed and then secured to ICD pulse generator. Defibrillation threshold was assessed and there was inability to shock the patient both at 21 joules, 31 joules and 41 joules in initial and reverse polarity. DFT did not improve even after placing Transvene lead (6937A -Medtronic) in the SVC. Subsequently after the azygos vein was cannulated and the Transvene lead (6937 A-Medtronic) was advanced and positioned in the azygos vein defibrillation could be successfully achieved at 21 joules. Post operative chest x-rays confirmed lead position (Figure 2C and Figure 2D)\nAfter the setting the camera at 25o RAO view a Guidant Rapido IC 90 is advanced and a clock wise torque is performed once the catheter is in the proximal SVC. A 20 cc syringe is utilized with a 50:50 dye mixture and once the distal portion of catheter is in a side branch, venography is performed (RAO/LAO view). After confirming the position of catheter in azygos vein a stiff wire is advanced and Rapido IC 90 is exchanged for a long safe sheath which is advanced and positioned in azygos vein (Figure 1B,C,D). A Medtronic Transvene lead (6937 A) is advanced and positioned in the azygos vein and then the sheath is gently peeled away.\nOUTPUT:" }, { "from": "agent", "value": "Left ventricular dysfunction, Nonsustained ventricular tachycardia" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 71-year-old female patient underwent multiple TURBT for recurrent UC from January 2016 (Table 1). On 29 July 2017, the patient underwent a TURBT and the pathological diagnosis was muscle-invasive high-grade UC. The tumor was small and no lymph node metastasis was detected on a CT scan. Thus, no neoadjuvant chemotherapy was administered. Extraperitoneal radical cystectomy with bilateral ureterocutaneostomy was performed on 16 August 2017. Pathological diagnosis of the resected bladder tumor was high grade UC, pT2, v-, ly+, pN0 (0/6). Based on the results of the pathological examination no adjuvant chemotherapy was considered. One month after the operation the patient presented with a high fever and severe leukocytosis without obvious infection. At that time, a CT scan revealed a mass on the left pelvic side (Fig. 1). Hypercalcemia (18.6 mg/dL serum calcium) was also present. Hypercalcemia and leukocytosis were suspected to be manifestations of paraneoplastic syndrome due to ectopic expression of PTHrP and G-CSF, respectively. On 18 October 2017, several tumor markers were examined. It was found that PTHrP (24.4 pmol/l; normal level, <1.1 pmol/l), SCC (45.3 ng/mL; normal level, <1.5 ng/mL) and beta-hCG (4.3 ng/mL; normal level, <0.1 ng/mL) were elevated; however, carcinoembryonic antigen, carbohydrate antigen 19-9, alpha-fetoprotein, neuron-specific enolase and pro-gastrin-releasing peptide were within the normal range. G-CSF was also elevated to 198 pg/mL (normal level, <30 pg/mL). Furthermore, the WBC count was increased to 37 000/muL (Fig. 2) and neutrophils accounted for 96% of all leukocytes. Hypercalcemia was successfully treated with 120 mg denosumab. Serum calcium levels were gradually decreased (Fig. 2). However, leukocytes reached 122 440/muL (Fig. 2). In addition, the mass volume had increased steadily on the left pelvic side (Fig. 1). The patient died on 12 November 2017 (<3 months after radical cystectomy). The time course of the disease is summarized in Table 1. Immunohistochemical staining of the specimens obtained during TURBT and radical cystectomy (Fig. 3) revealed positive staining for beta-hCG.\nOUTPUT:" }, { "from": "agent", "value": "Bladder cancer metastasis" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 46-yr-old woman was referred to Chungbuk national university hospital for thymectomy in February, 2013. Two months ago, she admitted for first developed ptosis, weakness in the neck, and dyspnea, and was diagnosed with acetylcholine receptor-positive MG. A chest computed tomography (CT) scan revealed a mass with calcification in the anterior mediastinum, which was suggestive of thymoma (Fig. 1). While undergoing cholinesterase inhibitor (Mestinon ) therapy, the patient developed a myasthenic crisis and was given immunoglobulin (Ig) therapy for 5 days under managed ventilator care. Treatment with corticosteroids then continued for a month. After the symptoms regressed, the patient was discharged. She visited the hospital again 2 months later for resection of the mediastinal mass. Given the clinical impression of thymoma-associated MG, mass resection and total thymectomy were performed. Macroscopically, the resected mass, which measured 4x3x1.5 cm, was a relatively well-demarcated nodule that was surrounded by fat. The cut section was hard, yellow to gray, and calcified (Fig. 2). Microscopically, the mass was composed of amorphous eosinophilic hyaline materials surrounding islands of thymic tissues (Fig. 3). Stromal calcification and ossification were noted. The associated inflammatory reaction consisted of small lymphocytes and occasional plasma cells. These eosinophilic substances displayed apple-green birefringence under polarized light microscopy after Congo red staining (Fig. 4). Immunohistochemical analysis revealed that they were positive for kappa and lambda light chains and negative for serum amyloid A. These findings were consistent with primary (light chain) amyloidosis. Further examinations were done to rule out plasma cell dyscrasia or lymphoproliferatvie disorder. The serum IgG, IgA, and IgM levels were normal. Serum and urine protein electrophoresis did not detect any abnormal bands. Serum and urine immunoelectrophoresis did not indicate any definite abnormalities. The serum calcium levels were also within normal limits. To screen for systemic amyloidosis, complete blood count, erythrocyte sedimentation rate, echocardiogram, basic metabolic and biochemical panel, and liver function tests were performed. All returned values that were within normal limits. The symptoms of MG were relieved dramatically after thymectomy.\nOUTPUT:" }, { "from": "agent", "value": "Localized thymic amyloidosis, 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: At the age of 4 years old the child presented to the emergency department with deteriorating level of consciousness and vomiting. The shunt was tapped and demonstrated increased pressure with good proximal flow and absence of distal runoff. A computer tomography (CT) scan revealed ventricles dilatation and periventricular edema Figure 1. Due to lack of alternative solutions, a decision was made to implant the distal catheter in the right atrium through the left subclavian vein with the help of the interventional cardiologist of the hospital. The peripheral catheter was introduced percutaneously using the Seldinger technique. Tunneling was done up to the clavicle region and a stab wound was performed at the puncture site. The subclavian vein was punctured using a 21 G needle and a 0,018'' guide wire was introduced. Through that, a 4-French sheath was introduced and the wire was withdrawn. Afterwards, a new guide wire 0,035'' was introduced and the sheath was also withdrawn. In order to achieve gradual vein dilation and to avoid injury of the vessel two consecutive sheaths of 6 and 7 French accordingly were used. The latter was a peel-away sheath Figure 2. The wire and the introducer were withdrawn and the distal catheter was introduced through the peel away dilator Figure 3. Placement of the catheter in the right atrium was confirmed with an intra-operative x-ray with the C-arm. The dilator was peeled away and the wound was closed in a standard manner. The patient made an uneventful recovery with no post-operative complications and he was discharged free of symptoms of increased intracranial pressure a few days later.\nOUTPUT:" }, { "from": "agent", "value": "Hydrocephalus, Bilateral internal jugular vein thrombosis" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: Two weeks after returning from the Amazon (Manaus, Brazil), a 40-year-old female developed fever, chills, headache, and myalgias with temperatures to 103.5 F, and saw a physician. She was not anorexic and had no abdominal complaints. She had been vaccinated for yellow fever and took atovaquone/proguanil for malaria prophylaxis. Her white blood cell (WBC) count was 6.9 K/muL (n = 3.9-11.0 K/muL), hemoglobin 9.8 g/dL (n = 11.6-16.3 g/dL), hematocrit 33.1% (n = 36-48%), and platelet count 411 K/muL (n = 160-320 K/muL). Her AST was 37 IU/L (n = 13-39 IU/L), and ALT was 50 IU/L (n = 4-36 IU/L). Headache and chills continued which prompted hospitalization. On admission, her review of systems was negative except for myalgias and left upper quadrant pain. Past medical history and physical examination were unremarkable. Her WBC count was 3.6 K/muL (atypical lymphocytes = 5%), hemoglobin 10.4 g/dL, hematocrit 33.5%, and platelet count 172 K/muL. Her erythrocyte sedimentation rate (ESR) was 26 mm/h. Serum ferritin was unelevated, and her lactate dehydrogenase (LDH) was 1167 IU/L (n = 100-250 IU/L). The left upper quadrant pain prompted an abdominal CT scan which showed mild splenomegaly. Blood smears for malaria and babesiosis were negative. Blood and stool cultures were negative. Dengue and chikungunya titers were negative.\nOUTPUT:" }, { "from": "agent", "value": "Acute Hepatitis A 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: The lesions showed a progressive increase in number and size and were not associated with local symptoms. The rest of the skin examination showed no data of interest. A histological study was performed that showed dermal occupation by mixed proliferation with elongated cells and multinucleated histiocytic-like cells of large eosinophilic cytoplasms with mild lymphocyte response. No significant atypia, mitosis, or necrosis was observed (Figure 2). The immunohistochemical study showed positivity for histiocytic markers CD 68 (Figure 3), vimentin (Figure 4), and alpha1 antitrypsin (Figure 5) and negativity for S-100, CD1a, factor XIIIa, and cytokeratins. The hematological study carried out included bone marrow cytology with discrete hypocellularity with dysplasia in 39% of the granulocytic series. Nucleus-cytoplasmic maturation asynchrony was observed in the red series. No increase in the number of blasts was observed. In bone marrow cytometry, hypogranularity was observed in the granulocytic series without excess blasts. The following IDH1, TET2, and KMT2A mutations were found in the NGS molecular biology study. The patient maintains periodic dermatological and hematological control. The skin lesions remained stable, and no type of treatment has been performed.\nOUTPUT:" }, { "from": "agent", "value": "Multiple Xanthogranulomas, Myelodysplastic 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 27-year-old man was admitted due to an unusually increased number of freckle-like pigmentation in sun-exposed areas, occurred when he was 4-month old. No photophobia or ocular lesion was noted. The patient was a computer engineer and had no neurological abnormalities. Review of family history revealed no similar patient. However, it was noted that he was born to consanguineous healthy parents and his parents were first cousins (Fig. 1A). We collected the data of the patient's clinical history, clinical findings and laboratory results. A skin biopsy from facial lesion was performed and the sample was fixed in 10% formalin and embedded in paraffin. Four-mum-thick sections were stained with hematoxylin-eosin. Peripheral blood samples were collected from the affected patient and the unaffected family members, including his parents and brother, as well as 100 healthy controls. Genomic DNA was extracted using DNA extraction kit (Omega, Madison WI, USA). The DNA samples were delivered to Invitrogen Company (Shanghai, China), then were amplified by polymerase chain reaction (PCR) and sequenced by ABI PRISM 3730 automated sequencer. The study was approved by the Ethical Committee of the First Affiliated Hospital, College of Medicine, Zhejiang University. All patients and healthy controls gave their written informed consents.\nOUTPUT:" }, { "from": "agent", "value": "Xeroderma pigmentosum, variant type" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: This 63-year-old man was admitted to the department of Neurology for neck and back pain, associated with asymmetrical paresthesiae and pain in the lower limbs (predominantly on the left side). Neurological examination showed distal amyotrophy and overall global mild weakness of the 4 limbs (total MRC was 84/100), with weak deep tendon reflexes (ONLS: 4/12). The association of idarubicine, cyclophosphamide, and dexamethasone induced improvement in the biological features (but with pain persisting in the lower limbs). CSF showed 10 white cells per mm3 with a mild elevated protein level (61 mg/dL). Except for significant positivity of the anti-Sjogren's-Syndrome-related antigen A antibodies (ratio = 2.6, positive if >1.4), immunological analysis was normal. Because of the persisting pain, a sural NB was performed. These cells were neither B-cells nor eosinophils; most of them were T lymphocytes and macrophages. No clonal B-cells were detected by conventional techniques. A steroid treatment (1 mg/kg/d during several months) was prescribed, with a significant neurological improvement (MRC: 94/100) and a dramatic decrease in pain (ONLS: 2/12) after 6 months.\nOUTPUT:" }, { "from": "agent", "value": "latent malignant hemopathy, peripheral neuropathy, B-cell lymphoma of ileum and cecum, herpes zoster, Basedow disease, myocardial infarction, low-grade lymphoma, necrotizing vasculitis" } ]

[ { "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 male with HCC presented with a skin rash after 21 months of nivolumab therapy. The patient had since been with cancer-free progression. The patient did not have any other side effects of nivolumab. The past medical history included hepatitis C, coronary artery disease, myocardial infarction, hypertension, and cervical radiculopathy. On physical examination, violaceous hypopigmented infiltrated plaques were seen on the pinna bilaterally, in the conchal bowl (Fig. 1), and on the neck (Fig. 2). Additionally, there was a 1-cm indurated plaque on the left side of the posterior neck and hypopigmented macules were seen on the left neck. Confluent, hypopigmented plaques with central areas of hyperpigmentation appeared in a photodistributed pattern on bilateral posterior forearms along with significant follicular plugging and perifollicular repigmentation. Skin biopsy demonstrated lichenoid interface inflammation with numerous dyskeratotic keratinocytes, pigment incontinence, parakeratosis, follicular plugging, and a dermal perivascular lymphocytic infiltrate (Fig. 3, 4). Direct immunofluorescence tests for antibodies to IgG, IgA, IgM, C3, and fibrinogen were negative. The ANA titer was 1:80 and the C3 and C4 antibodies were normal. Nivolumab was stopped following the drug reaction and the patient started hydroxychloroquine and topical steroids (topical clobetasol was used daily for a week followed by triamcinolone three times daily) along with sun protection. The symptoms improved by 80% after these measures. The patient was restarted on nivolumab 2 months after the initial eruption. At a follow-up visit 1 month later, there was notable clearing of the pinna and posterior neck; however, patches of hypopigmentation on the forearms and dorsal hands remained (Fig. 2). Anti-Ro and anti-histone antibodies were negative at this time.\nOUTPUT:" }, { "from": "agent", "value": "Discoid Lupus Erythematosus" } ]

[ { "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 man presented to the emergency room with sudden onset of fever, dyspnoea, bilateral pleuritic thoracalgy, and an exanthematous vesicular rash. He was a smoker and his two year-old son had chickenpox two weeks earlier. The patient had no previous immunization or known contact with the disease. On examination, he was febrile (39 C) with signs of respiratory distress (oxygen saturation of 88% on room air). An extensive polymorphic pruritic rash with macular, vesicles, pustules and crusty lesions was noticed (Fig. 1). Laboratory studies showed mild thrombocytopenia and elevation of liver enzymes (AST, ALT, GGT) and lactate dehydrogenese (LDH). Chest X-ray revealed multinodular interstitial infiltrates in both lungs (Fig. 2). Arterial blood gases were consistent with hypoxemic respiratory failure (PaO2 of 51.8 mmHg). HIV testing was negative. Excellent clinical and radiological evolution was documented, as was analytical normalization. After one week of therapy, the patient was discharged fully recovered. Male gender and tobacco use are know risk factors. Respiratory symptoms, mainly dyspnoea and dry cough develop after a few days of rash onset, although pleuritic chest pain and haemoptysis can occur. Patients usually demonstrate progressive hypoxemia and chest radiographs reveal diffuse bilateral infiltrates. Supportive care and acyclovir are the mainstay of treatment. The vast majority of healthy adults exibhits complete recovery.\nOUTPUT:" }, { "from": "agent", "value": "Varicella pneumonia" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 23-year-old man came to our hospital for routine surveillance cystoscopy. He had no symptoms, such as upper tract infection, flank pain, and hematuria. He was born with a lipomyelomeningocele and neurogenic bladder with low bladder compliance. He had been undergoing clean intermittent catheterization and taking anti-cholinergic agents since he was 3-years old. However, his neurogenic bladder was unstable, and his bladder capacity decreased and his bladder compliance worsened. He hence underwent sigmoidocolocystoplasty when he was 8-years old. His postoperative course was stable, and his bladder capacity increased and his urinary continence improved. The patient has been undergoing annual routine surveillance cystoscopy from 1 year after the bladder augmentation. The patient has no family history of bladder and colorectal disease. There were and no abnormalities on laboratory data before cystoscopy. Tumor markers, such as alpha-fetoprotein, carcinoembryonic antigen, and carbohydrate antigen 19-9 were not increased. Upon cystoscopy, there were no abnormalities around the anastomosis between the native bladder and sigmoid colon. However, a 5-mm pedunculated polyp was found on the front side of the sigmoid colon cap, and hence we performed a biopsy (Fig. 1). 2). Therefore, we performed snare polypectomy together with electrocoagulation under cystoscopy (Fig. 3). The patient's postoperative course was uneventful and his bladder function was maintained. 4a,b). During the subsequent 5 years, there has been no evidence of recurrence.\nOUTPUT:" }, { "from": "agent", "value": "Tubular adenoma" } ]

[ { "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 Caucasian female presented with abdominal pain, weight loss, nausea, and vomiting. She also suffered from chronic diarrhea. This had been ongoing for two years following a subtotal colectomy and ileosigmoid anastomosis. The subtotal colectomy was for clostridium difficile colitis not responsive to antibiotics. She also used medical marijuana for pain control due to an opiate allergy. Medical management of her diarrhea was ineffective. Her medical history included depression and migraine headaches which were both well controlled with medication. After a discussion with the patient, an informed consent was obtained for an exploratory laparotomy. Nonoperative management was not contemplated given her long standing issues with diarrhea as a result of her initial surgery for colitis. Intraoperatively she had an obvious compression of the third part of the duodenum (Figure 10). Initially after mobilization of the duodenojejunal flexure an attempt was made at duodenal derotation (Strong's procedure). Intraoperatively this resulted in bowel ischaemia due to malrotation of her mesentery as a result of a previous ileosigmoid anastomosis following a subtotal colectomy. Strong's procedure was abandoned and a Roux-en-Y duodenojejunostomy was performed (Figure 11). Her recovery was uneventful and she was discharged home. Her two-year follow-up showed complete resolution of her upper GI symptoms.\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: Before etanercept, he received 78 sessions of narrow-band UVB phototherapy, methotrexate (discontinued due to elevated liver enzymes after 1 year), and acitretin (discontinued by himself after 2 years). Past medical history was unremarkable. Eleven months after initiating etanercept, the above-described lesions and multiple affected joints were observed on the body. Etanercept was then discontinued due to gradual loss of efficacy and the extensive lesions. Skin examination revealed erythroderma with thickened skin, well-demarcated, brownish lichenification on the back, swelling of extremities and some small joints, lichenification on the knees and toes, and sunken scars on the right leg. Myxoid cysts, which could spontaneously break open, were found on the arms and finger joints (Figure 1A-D). Biopsy of the skin near the abscess on the right shin showed marked hyperkeratosis with parakeratosis and Munro micro-abscesses formation in the epidermis. Acanthosis, irregular elongation of rete ridges, and dilation of papillary blood vessels could be seen (Figure 2A). Alcian blue stain showed mucus cells and excessive mucin deposition in the dermis (Figure 2B). Laboratory tests showed normal liver, kidney, and thyroid function. The patient received topical corticosteroid ointments twice daily, which gave little clinical improvement within 1 month. However, to our surprise, at a 6-month follow-up, he returned with complete resolution of the lesions and swelling of joints and extremities, leaving hyperpigmented spots throughout the body (Figure 3A and B). The patient denied any systemic treatment. Another skin biopsy was then taken from the right arm's pigmented lesion, which showed no mucin deposition in the dermis (Figure 4).\nOUTPUT:" }, { "from": "agent", "value": "Secondary Generalized Cutaneous Mucinosis, Psoriasis, Psoriatic Arthritis" } ]

[ { "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 infant has frequent regurgitation since birth and for 2 months has been showing signs of irritability and difficulty gaining weight. She showed partial improvement with postural measures.\" The following questions were formulated for each of the two clinical scenarios, and respondents were asked to answer them according to their medical practice: 1- Would you request any diagnostic tests? If the answer is yes, what is the first test? ; 2 - Would you prescribe any medication? If yes, what would be your first prescription? ; 3 - Would you modify the diet? If yes, what is your first recommendation?, and 4 - What sleeping position in the crib would you recommend? Alternatives were offered for all questions as shown in Tables 1 and 2 of the Results section. The interview files included brand names of dietetic products and medications. If the answer is yes: 1 - Do you request any diagnostic test? If yes, what is the first test to be requested? Statistical analysis was carried out using Epi-Info software, release 3.2.2 (Atlanta, GA, USA) to calculate the chi-square test.\nOUTPUT:" }, { "from": "agent", "value": "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 female in her seventies was transferred to our hospital with severe headache and vomiting lasting for 4 days. 1A and 1B). The anomaly of ACA was also visible on heavily T2-weighted magnetic resonance images (Figs. 1C-1E). The patient was diagnosed with aneurysmal SAH of Hunt and Kosnik grade 2 and World Federation of Neurological Surgeons grade 2. As endovascular treatment was considered to be inappropriate due to the irregular shape and a broad neck of the aneurysm, elective surgical clipping was performed at 12 days after the onset of SAH when a risk of delayed cerebral ischemia passed. As DSA revealed multiple recurrent arteries of Heubner (RAHs) arising around ACoA (Fig. 1B), anterior interhemispheric approach (AIH) was selected to visualize these perforators clearly. The IOA and bilateral fenestrated A2 were found during microsurgical dissection. After full exposure of the aneurysm and main perforators, it was revealed that one of two RAHs branched off directly from the aneurysmal dome and that a small cortical branch adhered to nearby the rupture point (Fig. 2A). These vessels were interrupted and the ruptured aneurysm was completely obliterated with tandem clipping using 4 Sugita Titanium II clips (17-001-01, 17-001-03, 17-001-81, and 17-001-86; Mizuho Co., Ltd, Tokyo, Japan) to avoid kinking of the bilateral A2 (Fig. 2B). Postoperative magnetic resonance images showed acute infarction in the left caudate head and internal frontal basal cortex owing to the vessels sacrifice (Fig. 2C).\nOUTPUT:" }, { "from": "agent", "value": "Ruptured Anterior Communicating Artery Aneurysm, Subarachnoid Hemorrhage, Mild Cognitive Impairment" } ]

[ { "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: Because of positive fecal occult blood test and elevated fecal calprotectin (705 mug/g), she underwent upper and lower endoscopy, to look for sources of gastrointestinal bleeding. Colonoscopy and histological examination of colonic biopsies taken during the procedure were unremarkable. Specifically, fundic biopsies showed a complete atrophy of the oxyntic glands and intestinal metaplasia, accompanied by a moderate inflammatory infiltrate composed of lymphocytes, plasma cells, eosinophils, and rare neutrophils. Helicobacter pylori search was negative after Giemsa-stained special coloration and immunohistochemical staining with anti-Helicobacter pylori specific antibody. A representative picture of these histological findings is shown in Figure 1. Fecal H. pylori antigen test was positive, and the patient received a triple therapy with amoxicillin, clarithromycin for 14 days and esomeprazole for 1 month. Subsequent fecal antigen negative test confirmed H. pylori eradication. However, in a follow-up upper endoscopy performed 15 months later, histological examination proved unmodified. AIG was confirmed after further laboratory investigations revealing the presence of anti-parietal cell antibodies (1/1280 titer). Anti-intrinsic factor antibodies were negative and vitamin B12 levels were normal (164 pmol/l). Serum gastrin level was not assessed, as the patient was on esomeprazole, and urinary methylmalonic acid and homocysteine levels were not tested.\nOUTPUT:" }, { "from": "agent", "value": "Autoimmune 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: A 65-year-old woman presented to our clinic with a 1-week history of sudden-onset visual loss in her right eye. She had poorly controlled systemic hypertension. She was otherwise healthy and had no prior ocular history except for mild nuclear sclerosis in both eyes. At the presentation time, her best-corrected visual acuity (BCVA) was hand motion in the right eye. The relative afferent pupillary defect was negative in both of her eyes, and intraocular pressure was normal. As shown in Figure 1 (Fig. An MH with an approximate diameter of 600 microns was noted. 1)). The patient has undergone a 3-port 25-gauge pars plana vitrectomy (PPV, Constellation Vision System, Alcon, Fort Worth, TX, USA). Internal limiting membrane (ILM) peeling was done. The surgery was followed by fluid-air exchange and the injection of a nonexpansile concentration of sulfur hexafluoride (SF6, Eyesun Teb Co, Tehran, Iran) (Figure 2 (Fig. 2)). BCVA of the patient increased to 20/320 and 20/60, one and four weeks after surgery, respectively. OCT images confirmed the complete anatomical closure of the MH and restoration of the outer retinal layers such as the external limiting membrane and the ellipsoid zone (Figure 3 (Fig. 3)).\nOUTPUT:" }, { "from": "agent", "value": "Macular hole, Submacular hemorrhage, Retinal arterial macroaneurysm" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: The patient is a Hispanic female diagnosed with homozygous FH at the age of 3 years old. Prior to diagnosis, she had developed multiple cutaneous xanthomas on her hands, feet, elbows, and knees (Figures 1, 2, and 3). Furthermore, the patient complained of chest pain during exertion. Prior to treatment, serum cholesterol ranged between 500 mg/dL and 900 mg/dL. When the patient was 3 years old, she was started on rosuvastatin and ezetimibe. The patient's cholesterol level did not improve; serum cholesterol remained between 600 mg/dL and 700 mg/dL, and serum LDL level was 358 mg/dL. Genetic mutational analysis confirmed the diagnosis of homozygous FH and demonstrated a LDL-receptor genetic mutation with a DNA base change from adenine to guanine. The patient's only family history was a cousin who also had been diagnosed with homozygous FH and underwent OLT. The patient's cardiac stress test showed no ischemic changes and echocardiogram demonstrated a normal aortic valve with only a trace amount of aortic regurgitation and mild mitral regurgitation, without aortic stenosis. Bilateral carotid artery ultrasound revealed intimal thickening and noncalcified plaques. Computed tomography angiography demonstrated moderate calcification of the aortic valve annulus; calcium-score screening of the right, left main, left anterior descending, and left circumflex coronary arteries was normal. Additionally, cardiac catheterization showed normal coronary arteries without evidence of stenosis or calcification, but also showed mild aortic supravalvular narrowing. The patient was started on LDL aphaeresis due to the exertional angina.\nOUTPUT:" }, { "from": "agent", "value": "Homozygous familial hypercholesterolemia" } ]

[ { "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: 33-year-old African American male presented with abdominal pain, nausea and vomiting for one day. The pain was sudden in onset, initially diffuse and later localized to the epigastric region, severe in intensity, intermittent, crampy in nature and associated with nausea and vomiting. Patient reported having \"lumps\" on the left side of his abdomen and was concerned about the swelling. The review of systems was positive for poor oral intake and nausea; negative for facial or neck swelling, dysphagia, throat/tongue swelling, respiratory distress, or triggers for exacerbation (trauma, dental work, unusual foods, excessive excitement, or sleep deprivation). Past medical history was significant for HAE type I diagnosed in 1997 at age 10 and asthma since childhood. He reported having 5-6 attacks of HAE a year although previously attacks were as high as twice per month, and typically involved the face and neck. He had an endotracheal intubation in his 7th grade for laryngeal attacks. It is unknown if there is any history of consanguineous marriage in the family. In the ED, patient was hemodynamically stable, afebrile and had oxygen saturation of 98% on room air. Clinical examination was positive for generalized abdominal tenderness to palpation, more pronounced at the left upper quadrant, but without any peritoneal signs. Laboratory results (from a year earlier) reported C1INH level 7 mg/dl (normal range 21-39 mg/dl), low C1 Esterase inhibitor function 13 (normal >67), Complement 4 serum levels of 8 mg/dl (normal range 14-44 mg/dl)]. White blood cell count at current presentation was 12,900 per m3 (87% neutrophils without bandemia). Computerized tomography (CT) of abdomen and pelvis showed diffuse small bowel wall thickening throughout the jejunum, left sided abdomen, and moderate volume diffuse abdominopelvic free fluid (Figs. 1 and 2). Patient was treated with C1INH concentrate IV, capsaicin topical cream, haloperidol, ketorolac, lorazepam, and ondansetron along with 1-L normal saline bolus. Following above-mentioned treatment, patient showed considerable clinical improvement and 12 h post treatment had complete resolution of all presenting symptoms including abdominal pain, nausea, vomiting and leukocytosis.\nOUTPUT:" }, { "from": "agent", "value": "Hereditary Angioedema" } ]

[ { "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 53 year old African American female presented to the emergency center complaining of a two day history of nausea and right upper quadrant pain. She stated that she experienced weight loss in the last year and a three year history of dyspnea with increasing fatigue. She attributed her weight loss to the difficulty of simultaneous eating and breathing. She denied dry mouth, dry eyes, hemoptysis, and epistaxis. She denied current and past tobacco, alcohol and illicit drug use. She had not seen a primary care physician regularly due to financial circumstances. The physical exam was significant for a cachectic appearance, temporal wasting, digital clubbing in all fingers on the left hand and fifth finger on the right, and xerosis on her lower extremities. Labs revealed hyponatremia, leukopenia, thrombocytopenia, macrocytic anemia, elevated liver enzymes, hyperproteinemia and hypoalbuminemia. Hepatitis B, C, and HIV tests were negative, B12, folate and TSH levels were within normal limits. ESR and CRP were elevated. An autoantibody panel was strongly positive for ANA and anti-SSA/Ro IgG autoantibody. Protein levels were elevated and a serum protein electrophoresis showed hypoalbuminemia and diffuse polyclonal hypergammaglobulinemia suggestive of chronic inflammation or autoimmune disease. Urine protein electrophoresis was insignificant. AP chest x-ray showed suspicion of emphysematous change in the upper lungs without infiltrates or effusions and cardiac enlargement. A thorax CT with contrast showed a faint right upper lobe subpleural peripheral groundglass opacification measuring 11 x 6.5 mm, and a soft tissue density left lung base likely atelectasis and/or partial consolidation Fig. 1. An echocardiogram showed the right ventricle (RV) and right atrium (RA) both to be mildly dilated, RV systolic pressure estimated to be 60-65 mmHg, moderate tricuspid regurgitation, mild to moderate pulmonic valvular regurgitation, and no definite evidence of ASD or PFO. Pulmonary artery (PA) pressure was 50/25 with a mean of 36. RV pressure was 50/9 with an EDP of 10. RA pressure mean of 9. RA saturation 73%, PA sat 70% and aortic saturation 90%. Pulmonary vascular resistance: 5.81 Woods. Fick cardiac output: 4.13 with a cardiac index of 2.91.\nOUTPUT:" }, { "from": "agent", "value": "Primary Pulmonary Hypertension" } ]

[ { "from": "human", "value": "As a physician engaged in clinical diagnostic reasoning, here is a case report from Pubmed, please analyze the input and accurately identify the diagnosis presented within it.\nINPUT: A 54-year-old man with no previous relevant medical history was admitted to the emergency department for a cough, fever and dyspnoea. On physical examination, the ratio of arterial oxygen partial pressure (PaO2 in mmHg) to fractional inspired oxygen ratio (PaFi) was 181 mmHg. In addition, the patient also had jaundice, without other stigmata of liver disease. A chest X-ray showed bilateral infiltrates, while a nasal swab PCR test was positive for SARS Cov2. Blood tests showed elevated inflammatory parameters, as well as progressive anaemia with evidence of haemolysis (Table 1). Results for acute infection by hepatotropic viruses, syphilis, HIV, cytomegalovirus, Epstein-Barr virus and Mycoplasma pneumoniae were negative. Direct antiglobulin test (DAT) was strongly positive for C3d and negative for IgG. Based on the DAT results, cold hemolysis-mediated phenomena was assumed, although cold agglutinins were not initially determined. Moreover, a battery of test was conducted without finding an underlying autoimmune, neoplastic or haematological disease. Treatment was initiated with methylprednisolone boluses (250 mg x 3 times) and methylprednisolone 1 mg/kg in a descending dose, with fluid warmer and plasma exchange for five sessions. He had not presented relapses after corticosteroid withdrawal and after a 6-month follow-up.\nOUTPUT:" }, { "from": "agent", "value": "Autoimmune Haemolytic Anaemia, COVID-19" } ]

[ { "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 31-year-old gentleman diagnosed with T-cell ALL after presenting with diffuse petechial rash, cervical lymphadenopathy, abdominal pain, and a WBC of 121 K/muL with 40% blasts (Figure 1). Cytogenetics showed 46,XY,add(13) (p11.2)[3]/46,XY[17]. No BCR/ABL was detected by FISH; CSF was uninvolved. T-ALL was CD4+/CD8+, CD2+, CD3+, CD5+ (dim), CD7+, and TdT (dim). He was treated with vincristine, daunorubicin, pegylated L-asparaginase, and prednisolone achieving complete remission (CR). He was referred for hematopoietic stem cell transplant three months later which was delayed due to chemotherapy complications. During this period, he received leucovorin and glucarpidase. Prior to the transplant, a bone marrow biopsy was negative, but revealed clonal TCR beta and gamma gene rearrangements. In addition, CSF showed numerous LGL-like cells. The patient developed high grade fever and over one hundred erythematous plaques on his trunk, upper extremities, and lower extremities (Figure 2). Skin biopsy showed NHNCgammadelta PTCL (Figure 3) as did staging bone marrow biopsy (Figure 4). The malignant cells demonstrated mature chromatin, LGL-like morphology with prominent azurophilic granules resembling those seen in patient 2's PTCL (see below). They coexpressed CD4, CD8, CD56, cytotoxic markers, and gamma- TCR. TdT was negative. Molecular studies of the PTCL demonstrated that both the T-ALL and PTCL shared identical clonal TCR rearrangement peaks for both TCR beta and TCR gamma (Table 1). Six months after initial CR, the patient was initiated on ICE therapy and intra-Ommaya reservoir methotrexate (later switched to intrathecal cytarabine). The skin lesions and CSF involvement initially resolved; however, he developed fevers, new generalized skin deltagamma-PTCL, nodal/hepatic progression by radiology, and CSF recurrence consistent with progressive disease. Bone marrow transplant was deferred, and the patient was admitted for hyper-CVAD chemotherapy. However, the patient requested transfer despite the worsening condition. Current clinical status is unknown.\nOUTPUT:" }, { "from": "agent", "value": "T-Cell Acute Lymphoblastic Lymphoma, Peripheral T-Cell Lymphoma" } ]