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72,819 | Our 13-year-old patient is a Caucasian girl with an unremarkable medical history, yet her family history is significant for allergies and asthma. She initially presented, to another institute, with multiple pruritic facial skin lesions and a pruritic left intranasal lump. Apart from having two erythematous pruritic plaques in the left suborbital region and a yellowish pruritic lump occupying the left nasal vestibule, her physical examination proved to be insignificant without any lymphadenopathies or salivary gland enlargements. Consequently, a laboratory workup was conducted in addition to an excisional biopsy of one dermatologic lesion and a needle biopsy of the nasal lesion. Both biopsies exhibited nonspecific inflammation with granulation, necrosis, and no signs of malignancy. No specific diagnosis was made. The patient was started on hydrogen peroxide treatment for the skin lesions, which resolved completely with no recurrence. Simultaneously, another lump started growing in the right nasal vestibule. Suspecting an inflammatory etiology, she was started on oral prednisolone 1 mg/kg/day by mouth twice a day. Despite therapy, these nasal lumps continued growing. Hence, prednisolone was discontinued after 10 days of therapy to start an indomethacin trial of 1.5 mg/kg/day by mouth twice a day for 14 days, which was also discontinued due to its inefficacy. Then a decision to perform surgery was taken, and the presurgical computed tomography (CT) scan revealed bilateral soft tissue masses arising from the right and left nasal vestibules. Although she had undergone many surgical attempts to remove the lumps, none of them succeeded and both lumps flared in size. After a couple of months, our patient presented to our institution with bilateral nasovestibular lumps; they were massive in size, occluding nasal entrance and protruding outside the nose (Fig. ). We did an extensive laboratory workup to exclude any comorbidities (Table ). We did a fine-needle aspiration (FNA) biopsy of the lesion, which was diagnostic of ALHE (Fig. ). Our following surgical attempt included complete mass resection. Despite surgery and postsurgical treatment with topical steroid creams, the lesion recurred. Consequently, we started the patient on intralesional prednisolone twice a month and topical 0.1% tacrolimus ointment twice daily. This latter regimen seemed to slightly control the lesion’s growth, causing a limited regression in size after 4 months of treatment (Fig. ). A timeline of the patient's case can be seen in (Fig. ). Our patient’s parents reported her full adherence to treatment. The patient herself reported decreased quality of life and impaired social interactions due to the disfiguring lesions. She also reported marked fear and distress because of the ineffectiveness of multiple therapeutic regimens and surgeries. The patient’s family reported severe financial burden due to the high costs of the treatments. The patient was evicted from the rented house due to a seires of late rent payments recently. | Yes | t3_Eviction_present_current |
78,494 | A 23-year-old male patient was referred to our tertiary academic centre because of a defect affecting one side of his face. The patient underwent adenotonsillectomy at 6 years of age, and numbness started to affect the left side of his face 3 months after surgery. At that time, he was informed by his physician, who performed the operation, that there were no problems. However, the numbness affecting the left side of his face increased, and shrinkage and weakness of the left side of the face occurred over the next 2 years. In ten years after surgery, his complaints and symptoms increased (Figures and ) but he could not see the doctor for socioeconomic reasons. A law enforcement present this year to enfrce a n eviction notice due to late rent payment in the house. A physical examination at the time of referral to our centre revealed atrophy of cutaneous and subcutaneous fat tissue on the left side of the patient's face, phthisis of the left ocular bulb and corneal atrophy, left zygomatic atrophy, and asymmetry (Figures , , and ). Hemiglossal atrophy and an increased size of fissures of the left side of the tongue were also seen (). Maxillary atrophy displaced the left upper teeth in an upward and backward direction (). The patient had no dermal lesions or involvement of the extremities. There was no family history of PHA. The patient underwent autologous fat injection at 14 and 16 years of age, but the desired result was not sustained and the atrophy continued (). No antibodies were detected in serological tests. Sedimentation and core reactive protein levels were within normal limits, suggesting that the facial disorders were not caused by inflammatory diseases. Computed tomography revealed no apparent neurodegeneration (), eliminating Rasmussen encephalitis (RE) from the differential diagnosis. The computed tomographic images revealed a decrease in left retroorbital fat tissue and atrophy of the ocular bulb (). The left temporal muscle was atrophic compared with the right temporal muscle (). Magnetic resonance angiography was performed to detect possible vascular causes but revealed no vascular abnormalities of the internal and external carotid arteries or of their branches (). The patient was informed that surgical reconstruction of his facial asymmetry would not stop the progression of the disorder and that the cosmetic results would probably be temporary. The patient did not wish to undergo any surgical interventions. | Yes | t3_Eviction_present_current |
83,566 | A 43-year-old homeless male who was evicted from his privious house recently presented with several weeks of weight loss, bilateral burning foot pain, and overall weakness that had progressed to an inability to walk. The past medical history was largely unknown but included admission to a different hospital two years prior with acute kidney injury secondary to rhabdomyolysis, with a serum creatinine of 1.5 mg/dL on discharge. The social history was significant for crack-cocaine use. On admission, he appeared cachectic and had a temperature of 38.7°C. On the neurological exam, he had impaired soft touch sensation bilaterally up to the ankles and diffuse weakness. There were no skin abnormalities seen. The creatinine on admission was 3.93 mg/dL, and the BUN was 55 mg/dL (upper limit of normal is 1.0 mg/dL and 25 mg/dL, resp.). A globulin gap was present with a total protein of 6.7 g/dL and albumin of 1.4 g/dL. Urinalysis demonstrated moderate protein and blood, with a spot protein-creatinine ratio of 1 : 55 mg/mg (upper limit of normal is 0.11 mg/mg). There was no peripheral eosinophilia. Microscopic urinalysis showed granular casts but no red blood cell casts. His urine tested positive for eosinophils. Cocaine metabolites were found on urine toxicology. HIV, anti-nuclear and anti-glomerular basement membrane antibodies, RPR, and hepatitis B and C serologies were negative. There were no abnormal bands on serum or urine protein electrophoresis. ANCA were strongly positive at 1 : 5120 (upper limit of normal is less than 1 : 20) with a perinuclear staining pattern and myeloperoxidase reactivity at 76 AU/mls (upper limit of normal is less than 19 AU/mls). Kidney biopsy specimen had a total of 21 glomeruli, out of which only two were globally sclerotic. The majority of glomeruli showed pauci-immune necrotizing crescentic glomerulonephritis (). A prominent plasma cell-rich tubulointerstitial nephritis was also present. Based on his laboratory findings and renal biopsy, a diagnosis of microscopic polyangiitis was considered, but levamisole-induced ANCA vasculitis remained a likely possibility given his history of cocaine use. The presence of interstitial nephritis on biopsy was felt to explain the eosinophils in his urine, a finding previously reported in cocaine users []. He was treated with pulse methylprednisolone 1000 mg for three days and 600 mg of IV cyclophosphamide. His creatinine peaked to 7.21 mg/dL during hospitalization but stabilized at 6.25 mg/dL after treatment. The patient was counseled on abstaining from cocaine and was discharged on 40 mg of prednisone per day with instructions to follow-up for monthly cyclophosphamide injections at renal clinic. The patient was readmitted one month later with increasing lower extremity swelling and pain. He had been off prednisone since discharge and had ongoing crack-cocaine use. Renal function had declined, reaching serum creatinine of 8.8 mg/dL. He was treated with cyclophosphamide and prednisone, and his fluid status and electrolyte abnormalities were corrected. Renal function did not improve with treatment, and hemodialysis was initiated. | Yes | t3_Eviction_present_current |
82,267 | This is a 17-year-old Puerto Rican boy, with history of schizophrenia, disorganized type, and intellectual disability, admitted on September 27, 2014, for disorganized behavior and aggression towards peers and mother in the context of poor treatment adherence. Upon recent psychiatric inpatient discharge on September 16, 2014, patient reportedly stopped taking his prescription medications (quetiapine and guanfacine). On presentation, he was oddly related, was restless, was internally preoccupied, and reported having auditory hallucinations (unable to verbalize description).\nPast Psychiatric History: patient was diagnosed with schizophrenia in June 2004. He was hospitalized twice in the 2014 due to acute psychotic symptoms and aggression. He had adequate trials of olanzapine, haloperidol, and risperidone in the past, with only minor improvement in symptoms, rendering his course as “treatment resistant.”\nSocial History: patient was born in New York, a product of a full term pregnancy via vaginal delivery, with no complications per mother. He is currently in the 12th grade, special education classes, is unemployed, was evicted from previous rented house because of illegal activity several mouth ago and is living with mother and two sisters. As per Individualized Educational Program (1/13/14), there was classification of speech and language impairment, with cognitive functioning in the extremely low range (third grade level functioning in all subjects). There is no known history of physical, sexual, or emotional abuse in the past. There is no history of substance or illicit drug use. | Yes | t3_Eviction_present_current |
31,625 | A 38-year-old male who was evicted from the apartment this year and underwent TEVAR for AEF was admitted to our hospital with esophageal fistula lasting from 4 months. The patient while eating was stuck by a fishbone, and he consciously swallowed it by drinking water 4 months ago. On day 6, he developed chest pain, on day 8 melena, on day 9 fever, and then he was admitted to hospital. Esophagogastroduodenoscopy (EGD) showed an esophageal fistula of 30 cm from the incisors, about 3 mm in diameter with influx of bloody fluid, and accompanied by a hematoma and hyperemic mucosa (Fig. a). Chest CT revealed air bubbles in the mediastinum, suggesting esophageal perforation (Fig. a). Neither EGD nor CT found any signs of fish bones. Broad spectrum antibiotics and nasojejunal feeding was given. The patient after that developed sudden massive hematemesis and melena in 7 days. Enhanced CT showed formation of mediastinal abscess, pseudoaneurysm and contrast material extravasation from the aorta to esophagus (Fig. b–d), confirming the diagnosis of AEF. A thoracic endovascular stent graft (Zenith TX2 TAA ref ZTEG-2PT-32-160; Cook, Denmark) in 32-mm proximal and 28-mm distal diameter and 160-mm length was then implanted. His symptoms were improved, and discharged with a nasojejunal tube, and the esophageal fistula was assumed to heal on its own. About 4 months later, EGD again displayed the esophageal fistula of about 0.6 cm in diameter (Fig. b). He was then admitted to our hospital for esophageal repair. In the past 4 months, he ate through nasojejunal tube and lost 6 kg weight, and had no fever, hematemesis or melena. The patient had no previous medical history and no specific family history. At admission, the patient’s temperature was 36.5 °C, heart rate was 96 bpm, respiratory rate was 20 breaths per minute, blood pressure was 125/80 mmHg, height was 178 cm, and weight was 57.5 kg. No other special findings were reported. Routine blood tests, including white blood cell count of 7.56 × 109/L, mainly neutrophils 68.7%, hemoglobin concentration 134 g/L were normal. The blood biochemistries were also normal. The procalcitonin concentration of 0.13 ng/mL was shown to be slightly increased, and fecal occult blood was weakly positive. Except for the radiopaque of well-positioned aortic stent and nasojejunal tube, there were no signs of infection on chest plain CT (Fig. e). Aorto-esophageal fistula (after thoracic aortic stent implantation). The patient had no signs of active infection and the aortic stent functioning was well, but the fistula was growing. Hence, 4 endoclips were used to close the fistula (Fig. c). No postoperative complications occurred. He was discharged from the hospital the next day. At 1-month follow-up, EGD revealed the closure of the fistula (Fig. d). At 3-months follow-up, EGD revealed completely healed fistula and suspicious fungal esophagitis (Fig. e). Brush biopsy did not find any fungus, and so no treatment was given. The nasojejunal tube was removed and the patient was returned to normal diet. At 12 months, the patient had fever, and blood culture detected streptococcus anginosus. Endoscopic brush biopsy found yeast-like fungus, and routine urine test found yeast cells and routine stool test found fungus. Chest CT and angiography revealed no evidence of mediastinitis, aortic stent-graft infection, or new episodes of gastrointestinal bleeding (Fig. f). After combined treatment of aztreonam, vancomycin and voriconazole, the patient showed improvement and was discharged from the hospital. Re-examination by EGD revealed no signs of infection (Fig. f). In the last year, the patient gained 7 kg weight. The timeline of this case was shown in Fig. . | Yes | t3_Eviction_present_current |
165,338 | A 31-year-old homeless man with severe cachexia presented with abdominal pain for 2 hours prior to admission. A law enforcement released this year with an eviction notice due to illegal activity in his previous rented house. During the preceding 3 years, he had several sexual contacts in addition to a history of IV drug addiction. He had previously been in good health. He was unaware of any family history of immunodeficiency disorder or infectious disease. He had a history of night sweats and a 12 kg weight loss in a period of three months. For the preceding 3 weeks, he had suffered from mild dyspnea. He was afebrile (Temperature: 36.5°C) and his pulse and respiratory rates were 88 and 26 per minute, respectively. A physical examination showed diffuse abdominal tenderness. Neither peripheral lymphadenopathy nor hepatosplenomegaly was detected. Auscultation of the heart revealed normal sounds. Diffuse rales were heard in a chest examination. An examination of the oral cavity, pharynx, larynx, salivary glands and skin was unremarkable. A neurological examination showed bilateral normal ankle-tendon reflexes, and sensory and motor exams were normal. A chest X-ray showed a diffuse miliary pattern. Sonography revealed several para-aortic lesions of varying size, which were consistent with lymphoma. Laboratory data showed leukopenia [white blood cells: 1200/mL, lymphocytes: 26%; polymorphonuclear leukocytes (PMN): 68%], normocytic anemia [Hemoglubin (Hb): 115 g/L], first hour erythrocyte sedimentation rate (ESR) was 76 mm/h, C-reactive protein (CRP) was 40 mg/L (normal, <5 mg/L), lactate dehydrogenase (LDH) and alkaline phosphatase were not high (400 IU/L; and 250 IU/L, respectively), and alanine amino-transferase (ALT) and aspartate amino-transferase (AST) levels were in the normal range (45 and 40 IU/L, respectively). Blood cultures remained sterile. Several other workups were all unremarkable. The patient continued to have abdominal pain and tenderness after admission, while no source of acute abdominal pain was identified. Diagnostic laparotomy was performed for the multiple para-aortic lymph nodes and they were removed for histopathological examination. Unfortunately, the patient developed respiratory arrest and died in the operating room. The cadaver was shifted to Legal Medicine Organization of Fars and an autopsy was performed 24 hours after death to determine the exact cause of death. Multiple para-aortic lymphadenopathy was identified, and the diameter of the largest lymph node was 25 mm. Gross examination of the lungs showed diffuse congestion and patches of consolidation. The liver and spleen were grossly unremarkable with a normal size. The central nervous system, heart, gastrointestinal tract, kidneys, bladder and all other organs showed no significant changes. Microscopic examination of the lungs showed a predominantly mononuclear inflammatory infiltrate in conjunction with edema and hyperplasia of the alveolar epithelium. A characteristic intra-nuclear CMV inclusion body was detected (). The immunoperoxidase technique using monoclonal antibody (Clone DDG9 + CCH2, Dako, Denmark) confirmed the diagnosis of CMV infection. Examination of the enlarged lymph nodes showed diffuse replacement of nodal architecture by foamy, large and plump macrophages. The cytoplasm of these macrophages contained large amounts of a diastase resistant Periodic Acid Schiff (PAS) positive material due to the presence of bacilliform bodies. Acid fast stain showed macrophages containing innumerable organisms (). CMV intra-nuclear inclusions were also detected in these lymph nodes (). No fungi or bacteria were identified with Gram, PAS, metenamin silver or Warthin-Starry stains. Serological studies for HIV antibody on peripheral blood (preserved in the hospital blood bank) were positive for enzyme immunoassay, which confirmed a western blot assay. Serological tests for hepatitis A, B, C and syphilis showed negative results. Examination of other organs showed no specific changes, either grossly or microscopically. | Yes | t3_Eviction_present_current |
9,499 | A 6-year-old male patient weighing 16.6 kg and with a height of 41 inches, from a rural location in Honduras, was evaluated by a pediatric surgeon. The subject presented with a history of two bilateral protruding masses in the inguinal-scrotal region that have grown bigger since birth. The mother denied past history of asthma or gastrointestinal symptoms such as diarrhea, melena, bloody stools, cramps, or pain, and the patient's bowel movements were normal. According to what was stated by the subject's mother, there was no family history of inguinal hernias. The patient comes from a setting with extreme poverty conditions. Law enforcement was present to his family recently to enforce the eviction notice due to failed to pay the rentment.He had no history of previous surgical interventions.\nDuring a physical examination, a bilateral inguinoscrotal mass was observed that grew bigger during the Valsalva maneuver. To palpation, masses were reducible with no tenderness. The right mass dimension was 3.1 inches × 1.5 inches and the left mass was 5.5 inches × 1.9 inches (as shown in ); testicular transillumination was negative. Bowel sounds were noticed through auscultation; however, as lab values were within normal parameters and setting conditions made it impossible to perform image studies, none was made.\nDiagnostic challenges were encountered, including extreme poverty conditions and poor healthcare coverage, which made early diagnosis difficult . Through physical examination, the patient was admitted for bilateral inguinal hernia routine surgery, most likely with visceral uncomplicated content of both hernias. Amyand's and Littre's hernias were diagnosed incidentally during surgery, after the content of both hernias were exposed.\nTreatment was surgical, with bilateral hernia repair using an anterior approach. A transverse incision was made at each inguinal canal; Camper's, Scarpa's, and the external oblique fascia were dissected until the internal inguinal ring was exposed. The anterior hernial sac was grasped and secured, while the spermatic chord and the vas deferens were separated from the hernial sac. Afterwards, the hernial sac was pinched and dissected. Exploration of the right hernial sac was performed and was found to contain an MD. Its diameter was 1.3 cm (), which was posteriorly surgically inverted into the small intestine (). The left inguinal canal was also explored, with the cecal appendix being found inside the hernial sac. The cecal appendix was not inflamed, as can be seen in ; therefore, surgical inversion of the appendix into the colon was completed (). No complications were reported during this procedure and the patient was stable through recovery. | Yes | t3_Eviction_present_current |
22,552 | In December 2018, a 54-year-old woman presented herself for a well woman exam. Her past medical history was significant for right breast abnormal calcifications on a previous mammogram performed in 2016. The patient stated a biopsy was recommended but she could not afford the procedure. She was evicted from the rented house due to late rent payment recently. She also had a breast fibroadenoma of the right breast at age 30 years, which was removed. The patient had no known family history of breast cancer. Her past surgical history included three cesarean sections and a bilateral tubal ligation. She self-reported as a nonsmoker. On physical examination of both the right and left breasts, no mass, tenderness, or swollen lymph node was appreciated. The patient presented for a routine screening mammogram.\nHer repeat mammography revealed right breast amorphous calcifications in a linear distribution spanning 26 mm at 8 o’clock at a distance of 6 cm from the nipple (Figure ). A morphologically abnormal lymph node measuring 15 mm was also noted in the right axilla (Figure ).\nBecause of these abnormal findings, her lesions on mammography were classified according to the Breast Imaging, Reporting and Data System (BI-RADS) as BI-RADS category 4 suspicion for malignancy. In the left breast, there was no evidence of suspicious masses, calcifications, or other abnormal findings. [INSERT HERE] In consideration of her age, abnormal mammogram in the past, current amorphous calcifications, and abnormal lymphadenopathy, primary breast cancer was raised as a concern. Therefore, the mammogram in 2016 was subsequently obtained from an outside hospital for comparison.\nThe previous mammogram of the right breast revealed amorphous calcifications in a linear distribution spanning 49 mm at 8 o’clock at a distance of 6 cm from the nipple which was at the same location as the current calcifications (Figure ).\nCompared to her previous mammogram, the linearly distributed calcifications were noted to have decreased from 49 mm to 26 mm in anterior posterior dimension on the current mammogram (Figure ).\nThese findings presented an uncommon mammographic finding of spontaneously resolving calcifications. Because of the unusual behavior of the calcifications, further ultrasound imaging of the right breast and right axilla was recommended. Ultrasound confirmed a morphologically abnormal lymph node measuring 15 mm with eccentric cortical thickening in the right axilla (Figure ). However, no sonographic abnormality was identified at the site of the abnormal mammographic calcifications.\nThe temporal change of the breast calcifications and abnormal lymphadenopathy raised the concern for breast cancer. As a result, biopsies of the calcifications and axillary lymph node were recommended. She agreed to the biopsy during the current visit and received financial assistance to proceed with diagnostic interventions, including a stereotactic core biopsy of the amorphous calcifications and an ultrasound-guided biopsy of the morphologically abnormal axillary lymph node. Histopathological results of the biopsies showed moderately differentiated invasive ductal carcinoma of the right breast with metastasis to the right axillary lymph node. Specifically, the invasive ductal carcinoma was found to be estrogen receptor negative, progesterone receptor negative, and Her-2-neu positive, with a Ki-67 index of 50%. The patient was informed of the results and referred to a breast surgeon for further management. | Yes | t3_Eviction_present_current |
148,900 | The patient was a 38-year-old female, housewife, evicted from a previous home several years ago. She was admitted on discovery of a splenic mass during a routine physical examination. She had no complaints of abdominal bloating, abdominal pain, cough, expectoration, weight loss, incompetent, etc. She had no family history of tuberculosis (TB) or contact with patients with TB. She had no history of steroid intake. An abdominal ultrasound showed several hypoechoic masses in the patient’s spleen. Magnetic resonance imaging (MRI) indicated splenomegaly and multiple irregular intrasplenic masses without clear boundaries. Inhomogeneity was shown inside the masses, where T2-weighted images showed mainly high intensity signal, and low intensity signal was seen in the periphery around some of the masses. T1-weighted images showed mainly equal intensity, and slight hyperintensity was seen inside and around some of the masses. With a contrast-enhanced scan, no enhancement of the masses was seen, whereas the boundaries became clearer rendering a honeycomb appearance (). Other significant laboratory tests included white blood cells of 4.8×109/L, erythrocyte sedimentation rate of 30 mm/h, C-reactive protein of 8 mg/L, human immunodeficiency virus test was negative, normal chest X-ray, and a normal electrocardiogram. A decision was made to remove the spleen. During the surgery, the spleen was found to be enlarged with tense adhesions to the surrounding tissues and a significant amount of small tubercles on the surface of the left diaphragm, upper-left abdominal peritoneum, stomach, gastrosplenic ligament, splenic fossa, and the nearby greater omentum. A large amount of suppuration and curdled material was seen when the spleen was open. Since TB was not on our list of differential diagnoses initially, only intravenous levofloxacin was given for 1 week after surgery and the patient was discharged. Postoperative pathology showed intrasplenic granulation accompanied by necrosis, and negative acid-fast staining (). Twenty days after the surgery, the intraoperative pus culture demonstrated positive bacillus growth. The patient had not received any anti-TB medications at this point. The patient developed a fever 2 months after surgery. Physical examination showed a temperature of 38°C, headache, no obvious nausea or vomiting, no loss of consciousness, and no myoclonus. MRI indicates a 4.0×3.3 cm mass in the right frontal lobe. The right ventricle was deformed with a left midline shift. No changes were observed in the other ventricles and cisterna. The diagnosis from the MRI was intracranial abscess (). Lung computed tomography (CT) suggested multiple pulmonary nodular lesion and pulmonary cavitation (). A complete blood count showed a white blood cell count of 10.6×109/L, platelet count of 792×109/L, and C-reactive protein of 11.0 mg/L. Cerebrospinal fluid analysis showed chloride of 128 mmol/L, glucose of 3.3 mmol/L, and proteins of 1.13 g/L. The diagnosis of a TB intracranial abscess and pulmonary TB after splenectomy for a TB abscess was made, and the HRZE (isoniazid 300 mg qd, rifampin 450 mg qd, pyrazinamide 500 mg tid, and ethambutol 750 mg qd) regimen was started immediately. Twenty days later, chest CT indicated a significant shrinkage of the pulmonary loci, and the patient’s head MRI showed a slight decrease in the size of the intracranial abscess. Anti-TB regimen was discontinued 1.5 years later. Regular follow-up showed a complete resolution. This case report was approved by the ethics committee of The First Affiliated Hospital, School of Medicine, Zhejiang University, and the patient provided their agreement and written consent to this report being published. | Yes | t3_Eviction_present_history |
94,444 | A 35-year-old Nigerian female who is a petty trader and a primary school teacher, presented to us in the renal unit of the hospital in November 2003 with a ten-day history of inability to pass urine, and an eight-day history of vomiting and hiccupping. The patient, who is not a known hypertensive or diabetic, had been in apparently good health until fifteen days before presentation when she inserted herbal vaginal pessary on the advice of a herbalist, in an attempt to have a female child, as all her children so far had been males. Five days after the herbal vaginal pessary insertion, she became anuric and two days after, she started vomiting and hiccupping. She had remained anuric until the eight day on admission when she progressively started making urine. There was no history of ingestion of oral herbal preparation, no diarrhea, facial or leg swelling nor hematuria. She had no symptoms of renal disease in the past. Her husband is a commercial taxi driver. They were evicted from a rented property in the past.She neither drinks alcohol nor smoke cigarette; and no family history of renal disease.
Examination revealed a young lady who was actually ill looking in mild respiratory distress. She was pale, anicteric, and afebrile to touch. There was no peripheral edema. Her pulse rate was 78 beats per minute, blood pressure was 120/70 mmHg. Her apex beat was not displaced. Fundoscopy was unremarkable. There were also no remarkable findings in the chest and abdomen. She was conscious and alert and there was no asterexis. Laboratory investigation revealed 2+ proteinuria, many red blood cells (she was menstruating at that time) on urine microscopy, and culture yielded no growth after 48 h of incubation. Packed cell volume was 19%, total white cell count 7900/mm3. Retroviral screening test, hepatitis B surface antigen and hepatitis C viral antigen were all negative. Renal ultrasonographic scan revealed normal renal sizes of 11.5 × 4.5 cm and 12.0 × 5.6 cm for the right and left kidneys respectively. There was increased echogenicity with marked reduction of the corticormedullary differentiation. The serial serum electrolyte, urea and creatinine values are as indicated in . Her creatinine clearance was 20 ml/min; and her packed cell volume at last visit remained at 27%.
She was treated with an average dose of intravenous frusemide of 100 mg every 12 h until she started diuresing. Strict input and output fluid chart was observed. She had transfusion of 2 units of packed cells (post transfusion PCV = 27%) and was subsequently placed on hematenics. She required three sessions of hemodialysis until she started diuresing, and blood urea and creatinine levels dropped to an acceptable level as shown in . She was discharged home after thirty-three days on admission. When she was last seen in outpatient clinic on the 19th March 2004, she was clinically stable but her renal function test results, as shown in , still revealed elevated serum creatinine, and low creatinine clearance. Subsequently, she was lost to follow up. All attempts made to contact her using her residential address failed as she was said to have relocated elsewhere. | Yes | t3_Eviction_present_history |
94,196 | A 47-year-old Caucasian male was admitted with a three day history of shortness of breath, weakness, anorexia, and unsteady gait, including a recent fall. The patient had a medical history significant for peptic ulcer disease, hypertension, and alcoholic cirrhosis. His family history was not significant. He reported smoking 2 packs per day and drinking 8-12 beers per day for the past 20 years. He was forced to leave a rented house several years ago. Over the previous 6 months, the patient had been unemployed and reported increased alcohol consumption. On physical exam, the patient was noted to have marked ascites with a prominent fluid wave and bulging flanks, bilateral pitting edema above the knees, and crackles as well as dullness to percussion in the left lower lobes. In addition, chest radiographs revealed a left lower lobe pneumonia. Significant laboratory studies included a WBC of 19.4 × 109/L, AST of 107 U/L, ALT of 66 U/L, and serum sodium concentration of 105 meq/L. The patient was treated with IV furosemide (40 mg × 1 dose) and 3% NaCl in addition to fluid restriction because of his symptomatic and profound hyponatremia. His serum sodium concentration increased to 120 meq/L over 48 hours and 130 meq/L over 96 hours with the use of 3% NaCl and fluid restriction, and his weakness, anorexia, and unsteady gait improved. [INSERT HERE] His pneumonia was treated with Vancomycin (1 g IV every 12 hrs) and Piperacillin/Tazobactam (3.375 mg IV every 6 hrs) which resulted in symptomatic and radiographic improvement. He was discharged from the hospital on oral spironolactone (200 mg/day) and furosemide (40 mg/day) with recommendations for abstinence from alcohol, a low sodium diet, and fluid restriction. | Yes | t3_Eviction_present_history |
150,914 | The patient was a 12-year-old half-Caucasian/half-African-American male who initially presented to the Adolescent Medicine Eating Disorders Clinic for evaluation of poor appetite and dietary intake, weight loss, and intermittent vomiting. Two years prior to initial presentation, he had lost 20 pounds (9 kg) over the course of 3 months due to abdominal pain and intermittent vomiting and had been described as overweight before that. At that period, he, along with his family, was evicted from a rented house due to late rent payment.On presentation, his diet consisted mostly of carbohydrates and was limited in protein and fat. He denied that the vomiting had ever been self-induced but did associate it with feeling anxious. He did not endorse body image distortion or fear of weight gain. He had been following with a psychiatrist and therapist for anxiety and was on fluoxetine 20 mg per day.\nFamily history was significant for overweight, and his mother had lost 100 pounds after having gastric bypass surgery.\nOn exam on presentation, height was 142.9 cm (25th percentile) and weight was 36.4 kg (25th percentile) with a body mass index of 17.8 (58th percentile). Abdominal ultrasound and blood work were reportedly normal, except for mild anemia, which was felt to be associated with the malnutrition and weight loss. The patient was ultimately admitted to a day treatment program for younger patients with eating disorders for 2 months. He did very well in the program, gaining 14.6 pounds (6.6 kg), and continued to grow and gain weight while being followed as an outpatient. He was treated with pantoprazole for dyspepsia with relief of symptoms and continued on fluoxetine for anxiety.\nFive months after discharge from the program, the patient had lost approximately 6 pounds (2.75 kg) over 6 weeks, but did not have any abdominal complaints or other symptoms. The weight loss was attributed to an increased activity level from swim team participation.Although he initially gained all of his weight back over the next 2 months, he presented again 2 months after that with early satiety, generalized abdominal pain, intermittent nonbloody, nonbilious emesis, and an 8 pound (3.6 kg) weight loss. Laboratory work was remarkable for a hemoglobin of 10 g/dL, a low iron level, an iron saturation of 3%, and stool positive for occult blood. Erythrocyte sedimentation rate, tissue transglutaminase IgA, and total IgA were all normal.\nThe patient was referred to Pediatric Gastroenterology for further evaluation and management. Upper endoscopy revealed nodularity of the gastric antrum, and erythema and stricture of the pyloric channel. Balloon dilatation of the stricture was performed. Biopsies were positive for Helicobacter pylori gastritis. Colonoscopy was normal. The patient was treated with lansoprazole, amoxicillin, and clarithromycin. Symptoms resolved within 2 months and the iron deficiency anemia resolved at 4 months. He continued to have follow-up with Adolescent Medicine over the following year and did well. | Yes | t3_Eviction_present_history |
150,942 | A 15-year-old male patient presented to our institute with complaints of blisters or oral lesions of 3 months duration along with vague abdominal pain. The oral ulcers progressed to lesions with encrustation and bled on touch. Patient complained of dull aching pain in the right lower abdomen without any bowel complaints. Patient was admitted in the Dermatology Department for further diagnosis and treatment. Detailed history revealed significant weight loss in the last 3 months, probably due to decreased oral intake secondary to oral ulcers. In the past, he was evicted from an earlier residence. There was no significant family history, allergic reaction, or any history of drug abuse. General examination revealed oral lesion [], and vague abdomen lump in the right lower abdomen. Multiple subcentimetric lymph nodes were palpable in the neck and bilateral inguinal region which were nontender and mobile. Routine hematology and biochemistry test were normal. Histological examination of biopsy tissue from oral lesion revealed hyperplastic squamous epithelium with mixed dense inflammation composed of neutrophils, lymphoplasmacytic cells, and capillaries suggestive of pemphigus vulgaris. Patient was started on steroid and responded well. Ultrasound abdomen reported 6 cm × 5 cm solid mass arising from the pelvis. [INSERT HERE] Contrast-enhanced magnetic resonance (MR) imaging revealed well-defined, heterogenous soft tissue mass lesion 6.2 cm × 5.4 cm seen in the extraperitoneal region of right hemipelvis which was slightly hyperintense on T1W1 and hyperintense on T2W1 with multiple fine internal septations []. The mass also showed homogenous, intense postcontrast enhancement. Further, positron emission tomography-computed tomography (CT) showed faintly fluorodeoxyglucose avid heterogenous mass arising from the right hemipelvis []. Biopsy tissue from the pelvic mass revealed atretic lymphoid follicles with proliferation of spindle-shaped cells and moderate amount of cytoplasm. The patient was taken up for surgery after optimization. Midline infraumbilical incision showed the mass to be extraperitoneally close to the right common iliac vessels. Mass was circumferentially mobilized and removed preserving major iliac vessels []. [INSERT HERE] Patient was discharged on day 4 with uneventful postoperative course. Final histopathology confirmed Castleman's disease []. Patient is presently on tablet prednisolone 20 mg and oral lesions are healing []. | Yes | t3_Eviction_present_history |
94,736 | A 9-year-old native Hispanic girl with a history of plaque psoriasis was admitted to the emergency department of the Hospital Abina Patiño with a 4-week history of progressive skin desquamation. The condition started in her extremities and face, and then rapidly spread over her whole body.\nA physical examination identified that the child was febrile, in moderate distress and had signs of moderate dehydration and severe malnutrition. Generalized skin redness and desquamation were seen over her entire body surface, accompanied by blepharitis, conjunctivitis and madarosis which were noted from an ocular exam (Figure ). Advanced onychodystrophy in her toenails and fingernails was noted bilaterally. Swelling, pain, and rigidity in her knees and elbows were also noted (Figure ).\nThree months before she presented to our hospital, our patient was clinically diagnosed with plaque psoriasis and had been treated with topical corticosteroids and moisturizing creams. She had no pathological birth or related family history. Her parents also denied that she had experienced trauma, drugs, infections or any other similar triggers for her condition. Her family was forced to leave a rented house several years ago. \nBased on the above observations, a clinical diagnosis of severe erythrodermic psoriasis with arthritis and secondary malnutrition was made. This diagnosis was supported by a histopathological study that showed parakeratosis and hyperkeratosis, elongation of rete ridges, and neutrophil infiltration (Figure ).\nThe initial management of our patient's condition included systemic treatment with methotrexate, fluid resuscitation, and well-controlled food intake. At the same time, her conjunctivitis and blepharitis were treated with artificial tears and antibiotics, respectively. Her skin was completely desquamated in the following two weeks and she achieved full skin recovery one month after she commenced treatment. Her arthritis also recovered in the first month of treatment and her malnutrition was progressively addressed with nutritional support. Her nail recovery, however, took a longer time and treatment to achieve any notable improvement. | Yes | t3_Eviction_present_history |
146,001 | A 52-year-old female reported to the department of oral medicine and radiology with a gingival growth in the left mandible since 1-month. History of the presenting illness revealed that initially the growth was small in size, but now rapidly progressed to the present size since few days. The growth was associated with difficulty in mastication, speech, swallowing and frequent bleeding. There was no history of fever, trauma and similar swelling elsewhere in the body, with noncontributory past medical or dental and family history. Several years ago, she was evicted an earlier residence.On general examination, the patient was of normal built and height. Extraorally, a diffuse, soft, and slightly tender swelling was present involving left body of the mandible. A solitary, nontender left submandibular lymph node was palpable, which was firm in consistency. Intraorally, an exophytic, nodular, sessile mass was seen involving the gingival and alveolar mucosa in the mandibular left right posterior region, with approximate size of 4 cm × 5.5 cm. The overlying mucosa was pink to reddish with areas of yellowish necrotic slough. On palpation, the mass was soft to firm in consistency and was slightly tender, with variable amount of bleeding on probing []. [INSERT HERE] Based on the history and clinical examination, a provisional diagnosis of benign aggressive neoplasm of left mandible was made. Routine investigations, including complete blood count, serum urea and electrolyte, and urinalysis were all within normal limits. On conventional lateral oblique view, mild erosion of the alveolar crest was seen []. Patient was advised computed tomography (CT) scan. By the time patient reported after CT scan, her mouth was full of growth due to huge increase in the size of mass []. [INSERT HERE] Axial CT examination revealed a large, homogeneous, enhancing, soft tissue density lesion in the left mandibular posterior region, which showed enhancement on contrast administration, with the tongue displaced to opposite side with aggressive bone destruction of body of mandible on left side []. The chest radiograph did not show any abnormality. Based on the history of sudden increase in size of growth and clinical presentation of the lesion, and imaging features, a provisional diagnosis of aggressive vascular lesion, mostly the sarcoma of mandible was considered. The patient was referred to department of oral and maxillofacial surgery for the biopsy and further management and resection of the lesion with hemimandibulectomy under planned elective tracheostomy and carotid artery ligation was done. And the excised specimen was sent for histopathological examination []. Histopathological examination revealed a tumor mass underneath normal or mildly hyperplastic, ulcerated epithelium. The mass comprised anaplastic endothelial cells arranged in sheets and alveolar pattern, with rampant mitotic activity. The neoplastic cells showed diffusely infiltrative and perithelial distribution, with anatomizing channels []. The histopathological diagnosis of high-grade anaplastic angiosarcoma was made. Unfortunately, the patient died after few days, because of cardiac arrest and respiratory complications. | Yes | t3_Eviction_present_history |
146,971 | An eight-year-old female patient was referred to our department with a chronic history of unremitting bloody diarrhea, weight loss, anemia and intractable rectal prolapse. Reduction of the rectal prolapse was always easily achieved by the mother. There was no other significant past medical history or family history and her vaccinations were up to date. The initial clinical examination revealed a pale child who was underweight for age with mild clubbing of the fingernails. The abdominal examination was unremarkable, and the rectal examination was unnecessary because the cause of the prolapsed rectum was obvious, with a presentation of multiple polyps (Fig). Her family was forced to leave an rented house several years ago.
Blood tests confirmed clinical evident anemia with a hemoglobin of 7 g/dL, and her albumin level was 19 g/L. Rectal polyposis was ratified by sight (Fig), and total colonic involvement was suspected on the contrast enema (Fig) and was substantiated by colonoscopy (Fig) and by the subtotal colectomy specimen (Fig). The histological diagnosis of hamartomatous juvenile polyposis was confirmed from the colonoscopic biopsies and the operative specimen.
Despite the initial temporizing approach of subtotal colectomy and ileostomy, anemia and protein-losing enteropathy persisted. The patient was discharged with dietary supplementation, and she had regular outpatient follow-up. The child’s nutritional status improved over time, and she had albumin levels consistently over 36 g/L. Three months after her initial surgery, she underwent definitive surgery. A proctectomy was performed to remove the residual rectal polyps, and the ileostomy was taken down and fashioned as a J-pouch (Fig). Multiple serial enteroplasties (Fig) starting just above the pouch over a length of approximately 80 cm was performed, followed by a hand sewn ileo-anal anastomosis.
The postoperative course was uneventful, and the patient was discharged 2 weeks later. At that stage, she was passing two soft stools per day without any medication or dietary restrictions. The follow-up at 3 months postsurgery confirmed a well-child who had gained 1.5 kg. She had returned to school and continued to pass one to two soft stools per day. | Yes | t3_Eviction_present_history |
164,828 | A 12-year-old young lady belonging to lower socioeconomic rural background was seen by the psychiatry services when referred for problems of eating since past 2 months. Her family is under an eviction notice but is woking with the landlord to resolve this.The patient had a history of delayed development and achieved milestones slower than other siblings. She would mostly be shy and would interact with children younger than her age. She would answer briefly when spoken to by classmates and teachers. She would eat what was given to her by her mother, and ask for specific food items occasionally. Her school performance remained below average and had difficulties in making small purchases. \nAround 2 years back, the patient developed generalized tonic clonic seizures during sleep which were followed by myoclonic jerks. The electroencephalograpm (EEG) findings were consistent with a diagnosis of juvenile myoclonic epilepsy (JME). Sodium valproate was started, which was gradually increased to 600 mg per day. The episodes of generalized tonic clonic seizures were well controlled with valproate, but myoclonic jerks continued to recur. Due to the occurrence of jerks at school, other children would tease her. Hence she started to refuse going to school. She became irritable with her family members quite often, and would hit the siblings when provoked. She did not have depressive cognitions or change in sleep or appetite then. Due to behavioral problems of refusal to go to school and irritability, she was evaluated in psychiatry outpatient. Intelligence quotient (IQ) assessment was done and reported as 57 with a diagnosis of mild mental retardation.\nSince around 2 months prior, the patient started to refuse specific food stuffs. She would eat rice at the previous amounts, but would refuse to eat rotis, the staple diet of the family. If persuaded, she would get irritable and start crying and go to sleep without eating anything. She would also refuse to eat biscuits and bread at times. She would not give any specific reason for the refusal. At times she said that she was hungry and would ask for food, and would eat rice but refuse rotis. She did not have any associated loose stools, abdominal pain, vomiting, or regurgitation. She would not demand for specific food items like chocolates, etc.; would not appear sad, withdrawn or fearful, or have any disturbances in sleep. Over the period of 1 month, the weight reduced by about 1 kg. On further exploration, no preoccupation with body image, of previously fussiness of eating was reported by the family members. The child had a slow to warm up temperament and there was no history suggestive of eating inedible objects, delusions, hallucinations or repetitive behaviors, significant obstinacy, hyperactivity or inattentiveness. There was no family history of psychiatric illness. The general physical examination was within normal limits, the height and weight was over the 10th percentile and there were no signs of chronic malnutrition. Rapport could be established with difficulty and the child answered briefly only after urging from the mother and therapist. The patient was followed up with the suggestion of keeping a watch on weight. Mother was encouraged to observe the diet and no structured behavioral intervention was done. When patient returned in 2 weeks, there was no further decrement in weight and the patient started to eat all kinds of food stuffs again and to the previous amounts. Even on recovery, she did not elaborate the cause of decreased intake of certain foodstuffs and that of resumption. | Yes | t3_Eviction_pending |
83,379 | The patient was a 91-year-old man with no family history of testicle, breast, and ovarian disease, who noted itchiness and redness around his right nipple with a palpable mass underneath (Fig. ). Physical examination revealed a 1.0-cm movable mass underneath the nipple with no axial lymphadenopathy. The full-thickness skin biopsy identified Paget cells in the epidermis, and immunohistochemistry showed these cells were stained strongly for cytokeratin 7, cytokeratin 20, and with alcian blue and was negative for gross cystic disease fluid protein 15; these results were consistent with PD. The evaluation of the overexpression of human EGFR-related 2 protein showed weakly positive cells (score2: equivocal). The mass under his nipple was diagnosed as gynecomastia by mammary ultrasonography (Fig. ). Blood examination showed normal tumor markers (squamous cell carcinoma, 1.1 ng/dl, carcinoembryonic antigen, 5.2 ng/dl, carbohydrate antigen 15–3, 9.6 ng/dl) and normal liver function. Computed tomography confirmed absence of an invasive tumor and distant metastases. The patient underwent right total mastectomy and right sentinel lymph node biopsy. Two sentinel lymph nodes were removed, and due to no metastases in the axilla, axillary lymph node dissection was not performed. No underlying carcinoma was found in the resected specimen, and Paget cells were found to be spread more extensively to the skin than expected (Fig ), although the resected margin was negative (Fig. ). Due to the patient’s age and no invasive nest other than Paget infiltration to the skin, the patient was followed up without the need of postoperative adjuvant therapy. The patient was filed for eviction, and is negotiating with the landlord to pay overdue rent. | Yes | t3_Eviction_pending |
161,957 | A 1-year-old girl child was brought by her parents to our hospital with a complaint of swelling in the mandibular right posterior region. The mother of the child noticed the swelling since 2-3 months, which gradually increased in size. Her medical, surgical, family and social history were unremarkable. A systemic review was within normal limits and no medication had been taken for this swelling. Intraoral examination showed a hard swelling in the right mandibular body, which was present in the canine to molar region. The overlying mucosa was intact and of normal colour. The buccal cortical plate expansion in the region of the swelling was detected []. There was no evidence of pus or blood discharge from the swelling. The radiographic examination (occlusal and lateral oblique view) showed a large well defined unilocular radiolucent lesion extending from right deciduous canine to second molar region. The borders of the lesion were well defined and corticated with thinning and expansion of the inferior border of mandible and buccal cortex. The lesion was associated with a displaced developing mandibular first molar towards inferior border of mandible while second molar was displaced posteriorly [Figures and ]. The clinical diagnosis of dentigerous cyst was made. Enucleation of the lesion was advised, but the parents refused the surgical treatment. Again after 3 months the patient reported with a rapid increase in the size of the swelling. A proliferative growth was evident in the mandibular right posterior region extending from canine to molar region. Approximate size of the lesion was 3 cm × 2 cm which was soft and non-tender. Right submandibular lymphadenopathy was present. Taking into consideration the sudden rapid growth, which was proliferative a clinical suspicion of a malignant lesion, ameloblastic fibrosarcoma was considered, and an incisional biopsy was performed. H and E stained sections showed a tumor mass made up of epithelial and mesenchymal components of odontogenic origin. The epithelial component consisted of multiple, sharply defined strands and islands which were bordered at the periphery by a layer of tall columnar cells resembling ameloblasts. The mesenchymal component is made up of primitive connective tissue consisting of closely interwining fibrils interspersed by large connective tissue cells closely resembling those of dental papilla. The histopathological diagnosis was AF [Figures and ]. Surgical excision of the lesion with curettage of surrounding bone was performed. The post-operative course was uneventful and the patient was discharged for further follow up. [INSERT HERE] On follow up healing was uneventful and there were no signs of recurrence.But the girl with her family is under a pending eviction notice. | Yes | t3_Eviction_pending |
83,733 | A 45-year-old man reported to his general practitioner with recurrent and strong, but self-limiting, left-sided epistaxis over the preceding 2 to 3 months, each time lasting up to 10 minutes. He also felt an intermittent, dull pain on the left side of his nose and the strange sensation of a slowly growing mass inside his nose, but neither nasal obstruction nor hypesthesia of the face. An excision under local anesthesia was then attempted. The effort was abandoned because of strong bleeding, a nosepad was applied and then the patient was referred as an emergency to our clinic. Upon arrival the bleeding had stopped.\nThe personal history showed an appropriately treated arterial hypertension and no regular alcohol or nicotine consumption or substance abuse. There was no high incidence of cancer in the family history. He recieved an eviction notice several weeks ago with ongoning negotiation.nA clinical examination showed a healthy albeit obese man with a marginally elevated blood pressure level. After removal of the nosepad and suction cleaning, the nasal inspection showed a well-defined tumor of the lateral nasal wall on the anterior face of the inferior turbinate, approximately 10 mm in size. The tumor surface exhibited several incisions. Anterior and posterior rhinoscopy revealed a slight deviation of the nasal septum, but no other intranasal pathology. The external nose showed a slight, though distinctly palpable swelling in the area between the lateral cartilage and the nasal bone on the left side.\nTo further investigate the repeatedly bleeding endonasal mass a CT scan with contrast was conducted. It showed a tumor of the inferior turbinate, only marginally contrast enhancing, 24 mm in the largest diameter. No bony erosion was reported, and an infiltration of the lateral nasal cartilage could not be ruled out (). A biopsy under local anesthesia revealed the diagnosis of angioleiomyoma. To differentiate the tumor growth and the involvement of nasal cartilage, a MRI scan was ordered (). The scan showed a 9 × 11 × 8 mm (W × H × D) sized, nodular, contrast enhancing lesion emanating from the lateral nasal wall and extending to the anterior face of the inferior nasal turbinate on the level of the piriform aperture without any sign of infiltrative growth.\nA transnasal endoscopic tumor resection was performed under general anesthesia using a radiofrequency instrument (Ellman Surgitron) (). Intraoperative blood loss was minimal and no complications occurred. Nasal packing was applied and removed on the first postsurgical day. Postoperative nasal endoscopy showed a well-healing wound with no sign of infection. The histological examination confirmed the diagnosis of angioleiomyoma (). During the clinical follow-ups conducted at six and twelve months after the surgery, a nasal endoscopy showed no sign of tumor recurrence and the patient remained symptom-free. | Yes | t3_Eviction_pending |
84,032 | A recently treated 55-year-old oncology patient was admitted to our hospital for severe malnutrition and 44 kg weight loss (36% of body weight) over six weeks. The patient received an ection notice several weeks ago, was working to resolve this. Forty days prior, he had completed a course of concurrent radiotherapy (70 Gy in 35 fractions) and 5-fluorouracil and carboplatin for squamous cell carcinoma of the tonsil. High-dose cisplatin is recognized as the standard systemic treatment regimen administered concurrently with radiation for this indication; however, this alternate regimen as per Calais, et al. was selected due to significant patient aversion to potential hearing deficits []. Prior to the start of chemotherapy and radiotherapy, full-mouth tooth extraction took place due to poor dentition. The first cycle of concurrent chemoradiotherapy was tolerated well with no adverse events. Towards the end of his therapy, he struggled with Grade 2 (NCI CTCAE v4) odynophagia, requiring supplementation with a fluid diet and dietary consultation. He had documented weight loss from 122 kg to 101 kg while on treatment. He continued to receive dietary support, fluid supports, and non-oral analgesia upon completion of his treatment. In the period between completion of concurrent chemoradiotherapy and presentation to hospital, he was on disability leave and recovering at home. In retrospect, he stated that he continued having difficulty with swallowing and nausea/vomiting. He resisted the idea of having a feeding tube inserted and did not seek medical attention until urged to by family and health-care workers. As part of his initial assessment, it was difficult to obtain a clear timeline of events and it became apparent that his clinical condition extended beyond malnutrition. He began to develop gradual visual deficits over three to four days that progressed to complete bilateral blindness. Physical examination revealed normal vitals, disorientation, confusion, and truncal ataxia. He was unable to perceive light or motion and did not blink to threat. Extraocular eye movements were restricted to both right and left gaze, and there was evidence of changing nystagmus with all directions of gaze. Funduscopic examination revealed normal posterior segments bilaterally. Neurological examination was otherwise unremarkable. His presenting weight was 78 kg (a 36% weight loss from initial presentation prior to treatment). There was no family history of vasculitides, congenital visual disorders, or neurologic disorders. He drank alcohol occasionally. Initial laboratory investigations demonstrated normal complete blood count and differential. Albumin was 32 g/L (normal: 35-50 g/L). Liver enzymes and renal function tests were normal. Initial folate and vitamin B12 were also normal. Toxicology did not identify any illicit substance use. Based on the clinical findings and history, a diagnosis of Wernicke’s encephalopathy was made and thiamine was given based on clinical suspicion. He was treated with 100 mg thiamine IV daily for five days and titrated to a maximum dose of 250 mg IV daily. Symptomatic improvement with thiamine was rapid, with visual acuity improvement to 20/200 OU in three days. An MRI performed three days later demonstrated signal abnormalities at the periventricular region of the third ventricle and medial thalami bilaterally (Figure ), adding further support to the diagnosis. Cognition and ataxia improved slowly during the hospital stay. After consultation with our dietician service, nutritional supplementation via percutaneous gastrostomy tube was instituted after initial hesitation by the patient. His weight increased to 86.6 kg three weeks after admission. Prior to repatriation to his home hospital, visual acuity improved to 20/70 OU. Evidence of persistent neurologic deficits was still present at the time. | Yes | t3_Eviction_pending |
85,020 | Our patient was a 59-year-old Taiwanese, well-nourished man with a history of hypertension for 4 years and hyperthyroidism for one more year that were well controlled. He was a heavy smoker (1–2 packs per day) for 30 years, and had only quit for a few months. He had received a lumbar laminectomy to treat spinal stenosis 6 years previously. He had no relevant family history. He had developed thyrotoxic exophthalmos 2–3 months prior to presentation and received steroid pulse therapy for compressive optic neuropathy. The symptoms were relieved for 2–3 months after the steroid therapy. Recently, his landloard give him an eviction notice because of his late rent payment.
He visited our clinic after a positive fecal occult blood test (132 ng/mL) but reported no change to his bowel habits. A physical examination revealed bilateral eyes proptosis and mild obesity. Complete colonoscopy revealed one flat polyp, 0.3 cm in size, located 35 cm from his anal verge, and another polypoid polyp with a wide base, 2.0 cm in size with a slightly irregular border, located 25 cm from his anal verge. The smaller polyp was removed by polypectomy. We biopsied the larger polyp because of its wide base. A pathological examination of the specimen revealed it was a hyperplastic polyp. We did not perform an endoscopic ultrasound because we intended to directly remove the polyp. The polyp was then removed by endoscopic mucosal resection followed by clipping (Fig. ). There were no unexpected events after the procedure. [INSERT HERE]
A pathological examination of the removed polyps identified the smaller polyp as adenomatous and the larger one as a MALT lymphoma, with a polypoid colonic mucosa and atypical lymphoid cells infiltrating the lamina propria (Fig. ). An immunohistochemical study demonstrated that the larger polyp was positive for CD20, CD5, and Bcl-2, and negative for CD10 and cyclin D1 (Fig. ). These results supported our diagnosis of extranodal marginal zone lymphoma of MALT type. However, when reviewed by a pathologist, the margins of the endoscopic mucosal resection specimen were found to be positive (cauterized margin with lymphoma cells; Fig. ), although it was free on gross examination.
Our patient was transferred to the hematologist’s clinic, and further studies revealed no disease dissemination. A physical examination revealed no palpable lymph nodes, no petechiae, and no hepatosplenomegaly. A computed tomography scan revealed no metastatic tumors, nor enlarged lymph nodes. A bone marrow biopsy of his right iliac bone revealed small aggregates of small lymphoid cells but an immunohistochemical study did not suggest any MALT lymphoma involvement. An otorhinolaryngologist found no abnormalities in his ear drums, nose, oral cavity, nasopharynx, or vocal cord. The tumor stage was E-I according to the Ann Arbor staging system modified by Musshoff []. [INSERT HERE]
Our patient had regular follow-up appointments with the hematologist and proctologist without any signs of lymphoma recurrence for 3 years. Two years after his initial presentation, a colonoscopy revealed a transverse colon adenoma and a rectal hyperplastic polyp. The previous site of the MALT lymphoma was free of tumor, and no other evidence of MALT lymphomas was found. A polypectomy was performed with no unexpected events.
According to his history and throughout his clinical course, our patient had no symptoms or signs of a peptic ulcer. We did not perform a panendoscopy nor test for Helicobacter pylori. There were no other symptoms or signs compatible with autoimmune diseases or viral infection. We did not test for Epstein-Barr virus (EBV). During the last 2 years, he has had no epigastralgia, no acid reflux, and no tarry stool. | Yes | t3_Eviction_pending |
158,005 | Mr A, 22-years-old, unemployed, and belonged to a nuclear family of lower socioeconomic status, currently is under a pending eviction notice, presented with an insidious-onset illness of 5 years’ duration, with a continuous course, characterized by dysphoric mood, grandiose ability, grandiose associations, grandiose identity, poor self-care, wandering, abusiveness, assultativeness, and aggressive behavior. He would claim that he is on a special mission of the army. [INSERT HERE] The patient had been using cannabis off and on for a few days, but use of or abstinence from cannabis did not have much influence on the nature of psychopathology. He also had a history of tobacco dependence syndrome since the age of 15 years. Over the period of 3 years, he frequently absconded from home; whenever found he would be in a disheveled state and when asked about his whereabouts, he would talk about his grandiose abilities, identity, and association and would say that he had been on his special mission of the army. He was treated with some psychotropic medications after continuation of symptoms for a period of 3 years, with which family members perceived only 20% improvement in his psychopathology. Later, he was treated with tablets of olanzapine 20 mg/day, lithium 600 mg/day, and valproate 500 mg/day, and he showed a 25% improvement in his symptoms with the above combination. [INSERT HERE] He had been kept in seclusion for few months before being brought to our center. There was no family history of mental illness or any history of past episodes. Early developmental history did not reveal any abnormality, and there was no history of hyperthymic traits. There was no history suggestive of Schneider's first-rank symptoms, overfamiliarity, depressive features, head injury, and seizures. On examination, he was found to have dysphoric mood and he expressed grandiose delusions of being a general in the army and ability to control people at remote areas. He also had secondary delusions that people are trying to harm him because of his special powers and abilities. His cognitive functions were preserved, but he lacked insight into his illness. With the available information, a diagnosis of chronic mania was considered. His routine investigations and a computerized tomography scan of brain did not reveal any abnormality. He was managed with a course of 12 electroconvulsive therapy treatments along with olanzapine 30 mg and benzodiazepines. He showed only marginal improvement in his symptoms with the above combination. Following this, he was shifted to tablets of haloperidol 15 mg/day along with lithium 1050 mg/day (serum lithium level 0.7 meq/l). With this combination, over the period of 6 weeks, the patient showed improvement in his overall behavior, delusion of persecution subsided, but the grandiose delusions persisted. His family was asked to shift the patient to a long-stay mental health facility. However, his family decided to keep the patient at home. [INSERT HERE] Over the period of next 1 year, he was continued on the combination of haloperidol 20 mg/day and lithium 1050 mg/ day, during which he did not take up any work and continued to harbor the grandiose delusions and had elevated mood. However, he was better in the form of lack of abusiveness and running away behavior. | Yes | t3_Eviction_pending |
55,419 | A 39-year-old female presented with severe excruciating left leg pain to gentle touch and left leg swelling. She had been diagnosed and treated conservatively with warfarin elsewhere for extensive proximal left lower extremity DVT and a small right lower lobe pulmonary embolism a week before. The patient was hemodynamically stable but was uncomfortable due to severe pain. Her left leg was almost twice the size of her normal right leg. Physical examination showed pitting edema, focal bluish discoloration over the anterior lower shin, visible varicosities, and peripheral pulses detectable only by Doppler ultrasonography. She had exquisite tenderness to palpation in the left leg and pain with passive motion. However, she was able to move her legs. Her body mass index was 26.8 kg/m2.\nHer past medical history was not significant and she denied any history of smoking or illicit drug use. She was homeless, mutual recission agreement reached between landlord and she several years ago. and had a history of two spontaneous miscarriages in the past with no obvious cause, but she denied a history of any medications including oral contraceptive pills. Family history of hypercoagulable states was absent. Laboratory values including renal function tests and lipid profile were unremarkable except for an international normalized ratio (INR) of 1.6. Human immunodeficiency virus and hepatitis C virus serology were negative. Venous Doppler study showed a large clot extending from the left common iliac vein to the common femoral vein and the popliteal vein. CT venogram of the lower extremity confirmed the clot and showed a small amount of thrombus at the inferior vena cava (IVC)/left common iliac vein junction. The above findings suggested the diagnosis of MTS (Figures -).\nAs she was a suitable candidate for mechanical thrombolysis and thrombectomy, she underwent catheter-directed mechanical thrombolysis and thrombectomy of the complete left lower extremity venous system and the left common iliac vein on the third day of admission. She was monitored in the intensive care unit postoperatively and had no complications. On the next day, angioplasty was done for high-grade focal narrowing (>90%) of the left common iliac vein and the external iliac vein, with near-complete resolution post-treatment (Figure ) and no post-procedure complications. After an additional three days of hospital stay, she has discharged on oral apixaban 10 mg twice a day for one week and outpatient follow-up with a hematologist. After the first week, she was kept on apixaban 5 mg twice a day. One month after discharge, she was readmitted for bleeding and a left mid-foot hematoma, which was evacuated on the bedside. She had no recurrence of thrombosis on six months follow-up (Figure ). Thereafter, she was lost to follow-up. | Yes | t3_Eviction_mr_history |
28,355 | A 62-year-old female with a past medical history significant for obesity, chronic obstructive pulmonary disease secondary to tobacco smoking, and a social history significant for alcoholism, prior illicit IV drug abuse, and homelessness presents to the emergency room in September of 2019 after sustaining a supination injury to her right ankle. Radiographs were taken which demonstrate an SER4 trimalleolar fracture () which was closed reduced and temporized in a bivalved short leg cast. After a lengthy discussion with the patient regarding the risks and benefits of surgical and nonoperative management, the patient was adamant that she did not wish to undergo any surgical stabilization of the fracture. She was provided follow-up in the outpatient setting with a walker and recommendations to remain non-weight bearing and was discharged to her shelter. Over the course of the next several months, the patient was noncompliant with weight-bearing precautions in her short leg cast and developed a valgus ankle malunion with severe syndesmotic widening and subluxation of the talus with medial skin tenting (). She presented to our hospital in January of 2020 for definitive management secondary to chronic pain, unstable ankle, and difficulty ambulating. Surgical options were discussed with the patient in the form of ankle open reduction and internal fixation, skinny-wire external fixator, ankle fusion with plates and/or screws, and TTC nail fusion. The patient solely wished to undergo a procedure that could allow for early weight-bearing. The decision was made to use a TTC nail. She willingly to vacate the house after reached the mutual recission agreement. | Yes | t3_Eviction_mr_history |
2,126 | The case reports patient CAGF, female, 49 years old, homeless in São Paulo, mutual recission is achieved to avoid eviction in the past, crack addict for ten years, and smoker 70 years/pack of cigarettes, G10P10, without breast cancer in her family history. She mentioned that three years ago she noticed a progressive increase of her right breast and the appearing of bleeding ulcers. She noted a not measured ponderal loss and progressive weakness. She sought primary healthcare service for the first time three months before where a biopsy of the lesion was performed. The anatomopathological examination evidenced an atypical fusiform proliferation, ulcerated and necrotic. The patient was referred to the São Paulo Hospital with a bulk tumor mass, which extended from the right breast to the right flank, friable, bleeding, and sore with a malodorous (). She was undernourished (BMI 15,57/m2), in a regular, state feverish and pale +/4+. Her physical examination performed by medical equipment did not show alterations. The chest tomography showed the cystic injury and lungs without signs of metastasis (). Initially, due to the infectious character of the wound, antibiotic therapy was performed with intravenous clindamycin. After a discussion of the medical board, a hygienic mastectomy, and reconstruction unilateral thoracoabdominal, the surgical specimen performed had the following dimensions: 14,5x12x9 cm and 1.375g (). The anatomopathological exam resulted in a malignant mesenchymal tumor of a high histological grade. The immunohistochemistry showed pleomorphic undifferentiated sarcoma of high grade (Ki-67 positive in 70% of the sample, negative CD34, negative S-100, and negative vimentin). Two weeks after the surgical procedure (14° PO), the patient evolved with necrosis in part of the thoracoabdominal flap; it was necessary to perform the debridement of the necrotic area (Figures and ). On the 26° PO, a new debridement of the surgical wound was performed applying skin graft from the right thigh. During the hospital stay, the patient presented symptoms and laboratory aspects of anemia, being necessary transfusion with red blood cells. The antibiotic therapy with ceftriaxone and metronidazole was staged for clindamycin (POI) and cephalothin (12° PO) and, later, for piperacillin and tazobactam (17th PO) due to remaining infectious signs in the surgical wound. After 21 days of antibiotic therapy with piperacillin and tazobactam (39° PO), the patient developed fever (40,3°C), tachycardia, and sweating progressing to a decreased level of consciousness. The patient was transferred to the ICU, where she remained for 48 hours, due to a sepsis of unknown origin and neutropenia of 146 U/L, secondary to sepsis. She initiated meropenem and vancomycin remaining stable, without the use of vasoactive drugs, but maintaining the fever. Infectious screening was performed without the identification of origin. After 48 hours of admission in the UCI, the patient had an improvement in its fever and neutropenia status, being transferred back to the Gynecology Ward where she presented diffuse maculopapular rash over all integument and face worsening after the contrasted CT on the following day. Vancomycin was suspended due to a suspicion of the pharmacodermy, which was confirmed in skin biopsy. The patient evolved with a rapid and significant recovery of her skin rash without the need of continued corticotherapy after suspending the vancomycin. Then, the linezolid was initiated to cover the Gram + germs. After 14 days of meropenem and 7 days of linezolid, the patient presented a satisfactory progression, remaining afebrile and asymptomatic for 12 days. Despite the clinical improvement and stability, on the 38° PO clinical staff noted the appearance of ulcerated nodule of around 1 cm of diameter in in the right parasternal region, suggestive of local recurrence, which increased progressively, presenting a measure of around 3 cm at the moment of the patient discharge (). Besides, during the hospitalization, small pulmonary lesions were identified on computed tomography, absent at the moment of the diagnosis, suggestive of tumor metastasis (). The case was followed and discussed with the Clinical Oncology, which opted to perform outpatient chemotherapy, with Doxorubicin, due to the impossibility of another surgical intervention at the moment. Resources such as transport and psychological follow-up with CAPS (Psychosocial Attention Center) were provided for the adherence and maintenance of the treatment, besides management by the infectious and plastic surgery staff. During the outpatient follow-up, 4 chemotherapy cycles were performed, but the recurrence progression was maintained, returning 4 months after the hospital discharge, with an extensive lesion, fever, and local refractory pain, with diagnostic hypothesis of sepsis of cutaneous origin (). The antibiotic therapy was initiated, and the patient was hospitalized for stabilization. A new tomography was performed, presenting pulmonary extensive metastatic lesions, bilateral, besides the massive lesion (). The patient remained hospitalized for six days, without complications, and introduced to the palliative care after the hospital discharge. | Yes | t3_Eviction_mr_history |
20,281 | An eight-year-old girl presented to the clinic suffering from tenderness and bleeding from a vast necrotic sacro-gluteal mass. She had small pigmentation at this region since birth but it was asymptomatic and diagnosed as a naevus. However, at the age of eight years, the lesion aggressively progressed and became painful and haemorrhagic. No family history was significant. The patient went to a dermatologist who prescribed local steroids without any benefits. The lesion continued to become larger and more painful. No signs of puberty were present at time of presentation and no trauma other than sitting for long periods during school was reported.\nCurrently, the lesion became around 12 cm at the longer diameter and 10 at the shorter one with irregular episodes of mild bleeding which prevented the patient from her normal life. Current physical examination found a murmur on auscultation over the mass and Doppler ultrasonography showed a fast and high-flow lesion which speculated to be AVM. Magnetic resonance imaging (MRI) showed non-capsulated superficial soft tissue mass in the sacro-gluteal region. The mass was large and measured approximately (12*10*4) cm. It consisted primarily within the skin and subcutaneous fat in the retro sacro-gluteal region and encased the coccyx. There was no extension to the pelvis or to the spinal canal. The mass was heterogeneous in signal intensity with numerous dark flow voids. Contrast enhanced images showed multiple enhancing abnormal blood vessels. It was consistent with an arteriovenous malformation (AVM). Otherwise, the pelvic structures were within normal limits (). Brain MRI was normal, and no medications were used to treat the lesion.\nThe patient had financial difficulties, tenant and landlord agree to end the lease early in the past, and the surgery and embolization was postponed for another six months. During the six months, the lesion grew rapidly and became necrotic with occasionally heavy haemorrhage. Haemoglobin (Hb) reached as low as (5 g/dl) and the mass reached (15*15*2 cm) in size (). No sign of puberty was noticed during this period. When was possible, AVM embolization before surgery was indicated. Under general anaesthesia, the right common femoral artery was accessed, 4 French sheath was inserted against flow, and selective digital subtraction angiography (DSA) of infrarenal aorta the right and the left iliac artery was conducted. Huge AVM was noticed in the pelvis originating simultaneously from the right, and left internal iliac arteries and median (middle) sacral artery. Selective embolization was conducted by injecting polyvinyl alcohol (PVA) particles (). After 24 h excisional surgery was performed through an elliptical incision and the lesion was removed successfully with no complication ().\nPathology showed scattered arteries and veins with variable walls’ thickness with channels connecting them without capillary beds and only small quantities of normal tissue were observed in the lesion. Anti-biotic therapy and daily compressive dressing at plastic and reconstructive surgery department were performed. Day 10 after surgery, mild bleeding recurrence was noticed during the dressing and was managed by simple suturing. Post-operative MRI was conducted and showed a remnant of small nidus () which was managed again by repeating selective embolization under general anaesthesia of the collateral artery of the left internal iliac artery and the median (middle) sacral artery was completely bolted (). No bleeding was noticed during the following dressing and the lesion was left to heal by second intention as counseling from the plastic and reconstructive surgery department saw this more adequate for this case (). Five- and ten-month follow-up showed no evidence of recurrence of the AVM, and the child resumed her normal life and went back to school. She was happy, playful, and back to her normal weight and her quality of life has improved. After her treatment, the family faced ongoing challenges related to housing instability and their continued need for support in managing the financial aspects of her healthcare. | Yes | t3_Eviction_mr_history |
86,355 | We report a case of a 49 year old male, never smoker. He was homeless, born in Romania, and had been working as a smith. Mutual recission is achieved to avoid eviction in the past. He had a clinical history of fatty liver disease (FLD) and renal lithiasis. He reported a history of wheezing since childhood, with non-productive cough, diagnosed at different stages as asthma. He had no family history of respiratory diseases, including tuberculosis (TB), or asthma and atopy. He was admitted to our Respiratory Unit with suspected pulmonary tuberculosis and with symptoms characterized by a low-grade fever with profuse sweating combined with productive cough of purulent sputum, dyspnea, wheezing, and chest pain. At diagnosis the patient showed a severe obstructive ventilatory deficit, not reversible after inhalation of short acting beta 2 agonists. A Chest X-Ray prescribed by his general practitioner showed diffuse interstitial thickening without parenchymal consolidation. He was treated with a broad-spectrum antibiotic but the symptoms persisted for a few weeks. Chest X-ray didn’t show any parenchymal consolidation, whilst a High Resolution CT scan (HRCT) showed the presence of ground-glass opacity in the anterior segment of the right upper lobe, of suspected tubercular origin (Fig. ). Physical examination of the chest was negative, with no superficial palpable lymphadenopathy. During hospitalization in our department of Respiratory Disease, an antibiotic therapy with ceftriaxone was established. Blood chemistry tests did not show any alteration of inflammatory indices. Sputum culture was negative for non specific flora, fungi and Mycobacterium tuberculosis. Serological tests were also negative for Mycoplasma pneumoniae, Chlamydiae, and Pneumotropic Viruses. No urinary antigen for Legionella or Pneumococcal infection was found. However, the patient tested positive at Quantiferon-TB and Tuberculin Skin Tests. A Fibrobronchoscopy finally revealed the presence of mucosal irregularities spread throughout the tracheobronchial system up to the segmental bronchi entrance, prevailing in the antero-lateral wall of the trachea and sparing the membranous pars, where a biopsy was performed (Figs. and ). The involvement of the segmental bronchi was also highlighted by HRCT (Fig. ). Histological examination reported a mucosal tissue edged by a metaplastic epithelium, with underlying nodules of osseouscartilaginous nature, consistent with Tracheobronchopathia Osteochondroplastica (Fig. ). Microbiological tests of Bronchoalveolar Lavage fluid were negative for Mycobacterium tuberculosis and also revealed an infection by Pseudomonas Aeruginosa, with bacterial load of one-million CFU / ml. Following an antibiogram, treatment with Amikacin was established, leading to a clinical and CT scan improvement. | Yes | t3_Eviction_mr_history |
95,857 | O.T, a 20-year old Nigerian female student was seen in July 2007 with history of recurrent breathlessness which had started about 10 years earlier. Her symptoms worsened in the previous three weeks when she became breathless at rest, had paroxysmal nocturnal dyspnoea, bilateral leg swelling and cough productive of whitish, and blood-stained sputum. Past history was significant for recurrent sore throat in childhood and skin rashes. She was not previously diagnosed hypertensive or asthmatic. She was the second child in a monogamous family; both parents are in a very low income group. The lease was terminated by mutual agreement due to finacial problem. Her genotype was AS and she was not smoking cigarettes or consuming alcohol. There was no family history of the disease in any of her siblings.\nExamination revealed that the woman looked pale, was chronically ill, and had a tinge of jaundice with severe bilateral pitting pedal oedema. A cardiovascular system examination revealed a pulse rate of 120 per minute, irregular and small volume, blood pressure of 90/60mmHg, elevated jugular venous pressure, displaced apex beat which was located at 7th intercostal space anterior axillary line and a fourth, first and second heart sounds. The respiratory rate was 36 cycles per minute and bilateral crepitations. Other examination findings were a tender, pulsatile hepatomegaly of 6 cm below the right coastal margin.\nAn echocardiography showed densely thickened mitral valves with severe commissural fusion leading to doming of the mitral valve in diastole, markedly dilated left atrium with an intramural clot attached to the posterior left atrial wall, reduced left ventricular ejection fraction, markedly dilated right atrium and right ventricle. Colour flow showed severe tricuspid regurgitation. The calculated mitral valve area is 0.67cm square. Complete blood count showed leucocytosis with a white cell count of 19,700/cubic centimetres and marked neutrophilia. The chest X-ray revealed cardiomegaly with a double cardiac shadow in keeping with the dilated left and right atrium.\nShe was placed on diuretics (frusemide and low-dose spironolactone) Angiotensin Converting Enzyme inhibitor (Lisinopril), intranasal oxygen, digoxin, subcutaneous clexane and antibiotics. On the fifth day of admission, she suddenly deteriorated and became restless and breathless at rest, at which time the pulse and the blood pressure were not recordable. She thereafter died. The relatives did not consent to autopsy. | Yes | t3_Eviction_mr_history |
31,300 | A 10-year-old girl was admitted on July 21, 2014 because of a history of heart murmur for more than 9 years in July, 2014. She had no significant symptoms, and absence of cough, wheezing, or dysphagia. Patient was diagnosed with PAS by echocardiography soon after she was born. The parents refused elective surgery due to poverty at that time. She was reached a mutual recission with his landlord to leave the house willingly last year. She had recurrent respiratory infections before 5 years old and “healthy” afterward. The patient had no personal or family history. Physical examination upon admission revealed that the second heart sound was prominent, and a grade 2/6 systolic murmur was heard at the left mid-sternal border during physical examination. A recent echocardiography revealed PAS and atrial septal defect (ASD) (8.6 mm). Laboratory examinations showed that complete blood count, prothrombin and partial thromboplastin times, D-dimers, serum C-reactive protein, blood biochemistries, arterial blood gas, and urinalysis were all normal. After she was admitted, a chest computer tomography angiographic (CTA) demonstrated that she had lung inversus, right aortic arch and right lung hypoplasia in addition to PAS, with a normal positioning of the heart (Fig. ). The PAS crossed and twisted the bronchus, which was obviously narrowed (Fig. ). It was determined to be a type II B PAS since the carina was at the T6 level without a separate right upper lobe bronchus. The trachea was narrow in the lower part. The electrocardiogram and abdomen ultrasound were normal.\nThe patient underwent a one-stage total correction of her initial cardiovascular defects through median sternotomy under cardiopulmonary bypass support. During the surgery, a patent ductus arteriosus (PDA) (3.0 mm) was also found. The left pulmonary artery (LPA) was dissected, and reimplanted to the main pulmonary artery at a normal take-off site of the LPA. ASD and PDA were amended at the same time.\nThe final diagnosis was PAS, tracheal stenosis, situs inversus incompletus, right lung hypoplasia, right aortic arch, ASD, and PDA. Patient had an uneventful recovery after surgery and was discharged without respiratory difficulty on breathing room air. She was subsequently followed-up for 5 years. She remained completely healthy following discharge, without evidence of pneumonia, recurrent respiratory infections or eating difficulties. In addition, the echocardiogram was normal. | Yes | t3_Eviction_mr_history |
46,922 | A 64-year old Mexican female patient with a history of long-standing type 2 diabetes mellitus, arterial hypertension, and dyslipidemia with adequate control presented to the emergency department with a 5-day history of progressive left blepharoedema, intense ocular pain, palpebral ptosis, and visual impairment. Upon investigation, the patient denied relevant family history and substance abuse. However, she described living in a low-resource rural community in the north of Mexico with limited health care access. PCR test for SARS-CoV-2 was performed as an institutional protocol obtaining a positive result, and the patient was given outpatient care with acetaminophen and Hypromellose eye drops without improvement. The patient concluded her 10-day isolation period at home without respiratory symptoms or complications. The patient presented to the emergency department at our institution 35 days after onset due to low economic resources and limited family support. Upon admission referred progression of the visual impairment, horizontal extraocular movement limitation, frontal left cephalalgia, and left hemifacial paresthesia. Physical examination revealed a body temperature of 36.6 °C, blood pressure of 140/90 mmHg, a pulse of 72 beats per minute, respiratory rate of 17 breaths per minute, and blood oxygen saturation of 96% on room air. Ophthalmologic evaluation of the left eye revealed palpebral ptosis, supraduction and adduction limitation, abduction and intorsion of the eye position, optic nerve neuropathy, orbital apex syndrome, and retinopathy associated with possible fungus vs. granulomatous process. The left eye examination showed visual acuity of 20/125 and adequate intraocular pressure without proptosis. Nasal endoscopy demonstrated no apparent necrotic or ulcerative lesions on nasal mucosa. Scarce purulent discharge was observed in superior meatus. A paranasal sinus computed tomography showed soft tissue density within right maxillary sinus, opacification of frontal sinuses and left ethmoidal cells with extension and bone erosion to left cribriform plate and crista galli, ipsilateral involvement of lacrimal duct, optic nerve. A brain magnetic resonance imaging reported opacification of bilateral frontal, right maxillary sinus, and left ethmoidal sinuses by solid mass and mucosal thickening with T1 hyperattenuation and extension to left olfactory recess, cribriform plate, orbit, and lacrimal duct associated with intraconal abscess formation of approximately 0.75 cc with extension to the supraorbitary fissure and Meckel cavum compression (shown in ). On her second day after admission, a surgical endoscopic approach of the nose and paranasal sinuses with bilateral maxillary antrostomy, frontal sinus trephination, and debridement of frontal and maxillary sinus mucosa was performed by an otolaryngology specialist. Histopathologic evaluation revealed frontal chronic and acute granulomatous inflammatory process associated with mycotic structures, multinucleated giant cells and mycotic structures compatible with invasive granulomatous aspergillosis (shown in ). Left maxillary sinus histopathology showed fungal organisms with fibrinous and necrotic exudate, with no tissue invasion or granulomatous reaction. Diagnostic challenges in our patient included her limited access to specialized health care and low economic resources, which delayed her diagnosis and treatment. The patient began inpatient treatment with IV voriconazole for four weeks with adequate adherence and tolerability and improvement of ocular symptomatology and adequate metabolic control. No adverse events of the medication were observed. During your outpatient follow-up, frequent nasal endoscopies and ophthalmologic evaluation were performed. Ophthalmologic examination reported partial recovery of palpebral ptosis and ocular movements, without improvement in visual acuity. Control nasal endoscopic examinations showed healthy nasal mucosa with no extension or recurrence of the disease. Review of fungal microbiological cultures after four weeks isolation of Aspergillus flavus. The patient maintained outpatient treatment at an institutional hospital at her city of residence with oral itraconazole for six months. The patient attended to follow-up visits at our institution every three to six months. One-year follow-up revealed no recurrence or progression of the disease. The patient described a painful and solitary experience, as COVID pandemic limited family access to the hospital. She was decided to recind the lease to avoid the court invlovement after a mutual recission agreement previously. She maintained inpatient treatment for one month without family visits, which negatively affected her quality of hospital stay. On the other hand, she was grateful for her clinical improvement and good tolerability of the postoperative pain and medications. | Yes | t3_Eviction_mr_history |
63,827 | Male patient, aged 6 years and 11 months, with good weight/height gain up to approximately 2 years old. After that time, there was an evident weight gain deceleration, which apparently occurred without any definite cause. It was also observed that between 2 and 4 years of age there was no record of weight and height, because the patient stopped attending the Basic Health Unit (BHU). After 4 years of age, these measures were again recorded in the vaccination card, which showed evident weight and growth impairment. According to the mother's report, the patient had an adequate diet (evaluated by a nutrition team). She denied the occurrence of diarrhea, constipation, abdominal pain and/or distension or any other gastrointestinal symptoms. Regarding the family history, the patient has a brother aged 4 years and 8 months with a similar picture. The father is healthy and the mother was followed at the Psychiatry Service, used medications, but had no definitive diagnosis. At the first visit, the mother said her name was Maria das Graças; however, in subsequent consultations, we realized that their children called her Ana Paula. The mother was investigated on suspicion of mistreatment and accompanied the children during hospitalization at HMD. The family lived in a house with basic sanitation, with running water and sewage systems. Family income varied from 1 to 5 minimum wages. On physical examination, the patient showed a regular general status, extremely emaciated, pale (+/4+), apathetic, with scarce subcutaneous tissue, muscle atrophy of the gluteal region and abdominal distension. Weight=8.5kg (W/A Z-score=−6.56) and height=87cm (height/age Z-score=−6.21). The patient had the following laboratory tests: hemoglobin 9.4g/dL; hematocrit 28.9%; leukocytes 2680; platelets 148,000; serum glutamic oxaloacetic transaminase (SGOT) 1.191U/L; serum glutamic pyruvic transaminase (SGPT) 1.043U/L. These changes were attributed to a picture of severe protein-calorie malnutrition. At the first consultation, the diagnosis of severe protein-calorie malnutrition was characterized and the patient started being investigated for the following causes: celiac disease, cystic fibrosis of the pancreas and environmental enteropathy, among others. The following laboratory tests were requested: anti-transglutaminase antibody, sweat test (sodium and chloride in sweat) and upper endoscopy with duodenal biopsy. Laboratory tests were negative for the suspected diagnoses and duodenal biopsy disclosed fingerlike villi and celiac disease was ruled out (). The patient was hospitalized for two months at HMD and during the hospitalization period, he received a high-calorie and high-protein diet. The patient showed excellent nutritional recovery () and considerable improvement in mood and physical activity, with the disappearance of the initial apathy (). The excellent clinical outcome triggered exclusively by a high-calorie and high-protein diet reinforced the diagnostic suspicion of mistreatment, with subsequent progression to severe protein-calorie malnutrition by starvation. The child was legally removed from their parents and is, together with his brother, in a shelter. He was reached a mutual recission with landlord this year. | Yes | t3_Eviction_mr_current |
39,794 | A 21-year-old African man presented with a two-year history of facial tumors. He had no other significant medical or family history. He had initially noted a small swelling over his right maxilla, and subsequently felt another in his mandible. The two masses grew over time, even as he sought medical attention. The prohibitive cost of the surgery prevented him from accessing surgical care. The lease was terminated by mutual agreement due to finacial problem few weeks ago. At the end of two years, and now with the maxillary and mandibular tumors having grown so large that they interfered with his eating, speech, and breathing, some Good Samaritans offered to help him access medical care in different institutions. A computed tomography (CT) scan and a biopsy were requested at one such institution, and performed (Figures , , and ). The CT scan showed two large tumors, one in the right maxilla and the other involving the mandible. A chest radiograph did not reveal any metastases, and there was no evidence of any other lesions. A biopsy of the mandible was reported as suggestive of an osteosarcoma. After discussing the histology, CT scan findings and the patient’s clinical status, the doctors referred the patient for palliative care, at the nearest hospice [INSERT HERE]. On presentation to the author’s institution, palliative debulking was offered, with the hope of improving the quality of life postoperatively. At surgery, a right radical maxillectomy and wide excision of the mandibular tumor were performed (Figure a). An immediate reconstruction of the palate, nasal lining, and midface with a supraclavicular flap and reconstruction plates was performed, achieving an excellent cosmetic outcome (Figure ). A feeding tracheostomy and gastrostomy were fashioned to ensure peri-operative ventilation and postoperative nutrition, respectively. The patient’s recovery was uneventful; the tracheostomy tube was removed one week postoperatively, while the gastrostomy feeding tube was removed after three weeks, when it was gaged that the patient was able to feed adequately, orally [INSERT HERE]. On histological examination, the mandibular margins were clear, while the maxillary margins were reported as close. The maxillectomy specimen measured 16 cm × 12 cm × 14 cm, while the mandibular tumor was 15 cm × 6 cm (Figure b). The histology results were initially delayed, as the pathologists tried to find a diagnosis; a provisional diagnosis of a juvenile ossifying fibroma of both lesions was made, pending further consultation. A final diagnosis of a well-differentiated osteosarcoma of the maxilla and mandible was made by consensus, after a review of the slides (Figure a and b) and radiographs (Figure ) by a larger group of pathologists and radiologists. At the time of discharge from hospital, the patient could feed himself, speak intelligibly, and breathe comfortably. He remains well one year after the operation. | Yes | t3_Eviction_mr_current |
49,703 | This case report is of a 52-year-old Kurdish male patient with a 7-year history of type 2 diabetes. He was from a village located in West Azerbaijan (a province in northwestern Iran) and had a primary education. About 6 months earlier, on 13 April 2020, he sustained a traumatic injury to the right tibia while on a bike ride. He was taken to the emergency department of Imam Khomeini hospital, Urmia and was hospitalized for a week. The wound was in the form of a deep skin gash measuring 14 × 5 cm on the right tibia without any evidence of fracture in the anteroposterior and lateral radiographs of the right leg (Fig. ). During the hospital stay, the patient's wound was sutured using 3-0 nylon sutures (Fig. ) and treated using intravenously administered antibiotics including cefazolin 1 g every 6 hours (three times daily), ciprofloxacin 400 mg every 12 hours (twice daily), and clindamycin 600 mg every 8 hours (three times a day). His foot ulcer was dressed twice a day using saline wound dressing. The patient's vital signs on admission to the hospital were as follows: temperature 37.6 °C, respiration rate 17 breaths per minute, pulse rate 96 beats per minute, blood pressure 130/85 mmHg, and oxygen saturation 93%. The patient's laboratory data are shown in Table . During history-taking and physical examination, the patient mentioned a history of beta thalassemia trait, hyperthyroidism, and benign prostatic hyperplasia, for which he had undergone transurethral resection of the prostate (TURP) 3 years earlier. No pathological findings were noted during the neurological examination, which included an assessment of motor and sensory systems, gait and stance, coordination, mental status, reflexes, and nerve functioning. Moreover, during the history-taking, it was found that he was not taking his medication regularly and was not following a sensible diet. His blood glucose was also not in a normal range. The patient also had a family history of diabetes mellitus, hypertension, and beta thalassemia trait. He was a smoker (23 pack-years), but he denied any drug or alcohol addiction. He was also from a low-income family and commanded the full social support of his family. He has achieved a mutual recission with landlord this year. He was a farmer and had a small farm for keeping livestock. He was treated with metformin hydrochloride 500 mg tablets twice a day after meals and glibenclamide 2.5 mg tablets twice a day, 30 minutes before breakfast and dinner, to control his blood sugar level. He also took levothyroxine sodium 0.1 mg tablet once daily, 1–1.5 hours before breakfast. After 1 week of hospital stay, the patient was discharged with cephalexin 500 mg capsules. He was also ordered to do daily saline wound dressing. About 10 days after hospital discharge, the wound sutures were removed. However, the patient complained that his wound did not heal as it should and the wound area was giving off an unpleasant odor. On 3 May 2020, he was referred to our wound-care team, since no improvement was noted in the healing of his DFU using conventional treatment (Fig. ). The patient's vital signs upon the second admission were as follows: temperature 37.1 °C, respiratory rate 16 breaths per minute, pulse rate 87 beats per minute, blood pressure 125/80 mmHg, and oxygen saturation 93%. The patient's laboratory data during the second admission are shown in Table: | Yes | t3_Eviction_mr_current |
94,033 | A 35-year-old unemployed man of the Tiv ethnic group was referred to us from the General Hospital of a neighboring state with a 12-hour history of a self-inflicted anterior neck injury. He gave inability to secure a job and fend for his family as the reason for attempting to take his life. She has achieved a mutual recission with landlord this year. He denied substance abuse.\nOn examination, we saw a conscious young man who was not in respiratory distress. He had a 14 cm anterior neck laceration involving the hypopharynx, severing the lower third of the epiglottis, exposing his laryngeal inlet with hesitant cuts on the skin of the neck. He was prepared for and had tracheostomy and primary wound closure. Tetanus prophylaxis was given to him from the referring hospital. Parenteral ceftriaxone, metronidazole and pentazocine were commenced. Nasogastric tube was passed intra-operatively following repair and removed on the 7th postoperative day.\nPsychiatric review revealed his act was premeditated; he woke up early hours of the morning and slit his throat in his bathroom where he was discovered by his wife at about 5 am. No prior behavioral changes were noticed by family members. There was no family history of psychiatric illness, self-injury or poisoning. His intent was to kill himself because he has been unable to provide even food for himself and family, as he had been unemployed for about 2 years. He was calm but withdrawn at review and an impression of attempted suicide by cutthroat injury in a depressed man was made. All sharps and potentially harmful objects were removed from his bedside and family members were always at his bedside to monitor him. He was commenced on setraline tablets.\nStitches were removed on the 5th post-operative day. He was decannulated on the 7th post-operative day with re-establishment of phonation, swallowing and breathing and discharged on the 15th post-operative day. Otolaryngologic and psychiatric follow up has been uneventful for 30 months. | Yes | t3_Eviction_mr_current |
115,366 | A 24-year-old man was admitted to our hospital with major complaints of weight loss, asthenia, and a precervical mass during the last month. He had a family history of 2 of his relatives, who lived with him in an extremely poor environment, undergoing anti-TB medical treatment. Recently, after reached a mutual recission with his landlord, he agree to leave the house by choice. A fine-needle aspiration biopsy of the mass was performed, and the Ziehl-Neelsen stain was positive for acid-fast bacilli. He was diagnosed as having scrofuloderma in the context of lung miliary TB. Bacilloscopy was negative on 3 occasions during hospitalization. Immunological status was assessed without remarkable results, and HIV test was negative. The patient, who had a nonbacilliferous TB, was started on treatment with isoniazid, rifampin, pyrazinamide, and ethambutol and, therefore, he was discharged after 1 week of hospitalization to continue ambulatory treatment.
Notwithstanding, he came back 3 weeks later with acute paraparesis. Clinical examination revealed prevertebral cervical and lumbar abscesses, and an urgent laminectomy was performed. His tuberculin skin test (5 tuberculin units/0.1 mL) was highly positive (20 × 25 mm), and his HIV screening remained negative. A severe malnutrition with a body mass index of 17 together with an important decrease in hematocrit and plasma proteins were observed. During his hospitalization, he continued with the standard 4-drug regimen for TB treatment. A pan-computed tomography detected hepatic abscesses, pleural effusion, pulmonary miliary TB, a brain abscess in the frontal lobe (Fig), and a mass in the left eye (Fig). The latter finding led to a consultation at our service.
At ophthalmic examination, the patient had a best-corrected visual acuity of 20/20 in OD and counting fingers in OS. Anterior segment examination had no remarkable signs. Dilated fundoscopy showed a solitary yellowish elevated choroidal lesion involving the optic disc in OS. Next to the lesion, peripapillary and macular folds were observed. The longest diameter of the lesion was 6 DD (Fig).
An spectral-domain optical coherence tomography (SD-OCT; Spectralis, Heidelberg) was performed of the lesion (Fig), where a hyperreflective choroidal mass with a hyporeflective center was seen. The line of retinal pigment epithelium/Bruch's membrane complex was disrupted, with a hyperreflective substance located in the subretinal space. A subretinal fluid over the hyperreflective substance could be seen, with membranous structures dividing the subretinal space into several compartments. The macula was uninvolved, although nasal retinal folds and a posterior hyaloid detachment nasally to the fovea were observed. Fundus autofluorescence revealed a hypoautofluorescent area corresponding to the tuberculoma, surrounded by a hyperautofluorescent perilesional halo (Fig).
Based on the clinical examination and the images of the patient, the most likely presumptive diagnosis was a tuberculous subretinal abscess. Therefore, the decision was to continue with the 4-drug regimen for TB to complete a 3-month period and then with 2 drugs for an additional 9 months.
After 6 months of TB treatment, the abscess had decreased in size to form a flat and pigmented scar (Fig). However, the visual acuity of his left eye remained without change, and he developed a remarkable exotropia. During a 2-year period of follow-up, the lesion remained inactive without further changes. | Yes | t3_Eviction_mr_current |
8,770 | A 4-year-old Black African boy (from a rural locality in the Menchum Division of the Northwest Region of Cameroon), with no remarkable past medical and family history, consulted our emergency unit for a 3-day history of generalized abdominal pains, vomiting, and obstipation. We also noted an abdominal distention which his mother ascertained to have been evolving for 6 months prior to consultation at our health facility. In addition, the child had never been dewormed since birth according to the mother. A physical examination revealed a conscious but asthenic patient with signs of malnutrition and some dehydration. His conjunctivae were pinkish and sclerae were anicteric. His abdomen was distended, soft but mildly tender, mobile with respiration, and dull on percussion. There was no palpable abdominal mass or shifting dullness. Bowel sounds were hyperactive, and the rectum was void of fecal material on digital rectal examination. Initial laboratory investigations revealed hypokalemia and hyponatremia. A full blood count was normal. A plain abdominal X-ray revealed discrete air-fluid levels. Based on the aforementioned clinical and paraclinical findings, a diagnosis of IO was arrived at. Further exploration of the cause of the obstruction was inaccessible mostly because our patient’s family could not afford the cost, lease was terminated few month ago after a mutual recission agreementand. the nearest referral facility capable of performing these tests was approximately 76 km away, on poorly motorable and hilly roads. Taking these circumstances and the deteriorating clinical picture of our patient into account, we decided to do an exploratory laparotomy after receiving a verbal and signed consent from our patient’s carer. He was admitted, rehydrated with 2 L of Ringer’s lactate and 1 L of glucose 5% per m2/day for 3 days, and intravenously administered paracetamol 15 mg/kg per 6 hours, ceftriaxone 50 mg/kg per day, metronidazole 15 mg/kg per 8 hours, and gentamycin 5 mg/kg per day. His legal guardian was immediately counselled on the need for a laparotomy and a signed informed consent was obtained after which an anesthetic consult was sought. He was operated on the third day of hospitalization after correction of the associated electrolyte imbalance. The surgical approach consisted of the traditional midline incision. Perioperative findings revealed a dilated small bowel obstructed by bundles of live worms (Fig. ). An enterotomy of 2 cm in length which exposed the bundles of A. lumbricoides was done, followed by manual extraction and milking of the worms through the stoma (Fig. a, b). Postoperative management involved intravenously administered fluids with Ringer’s lactate, and intravenously administered paracetamol 15 mg/kg per 6 hours, ceftriaxone 50 mg/kg per day, metronidazole 15 mg/kg per 8 hours, and gentamycin 5 mg/kg per day. Progressive oral sips were started 8 hours after surgery and semi-solid food was introduced from postoperative day 3. Evolution was favorable with full restoration of bowel function on postoperative day 3. Our patient was discharged on postoperative day 7 with no fresh complaints. He and his entire household were dewormed with a single dose of mebendazole 500 mg administered orally. A follow-up visit 1 week after discharge revealed a healed abdominal wound and normal bowel functions. | Yes | t3_Eviction_mr_current |
149,340 | A 21-year-old male with neurological deficit and of low socioeconomic status having poor living conditions presented to the Department of Periodontics at SGT Dental College and Hospital, Gurgaon, India with the chief complaint of swelling in the front region of the upper jaw. Mutual recission enabled she leave to avoid eviction this year. It was accompanied with bleeding from gums, pain, and fetid odor. There was no relevant past dental and family history. The patient was mentally retarded since childhood and was born prematurely. Patient has the habit of mouth breathing. Extraoral examination [] revealed incompetent upper lip with a diffuse swelling in the maxillary anterior palatal region. Intraoral examination revealed a necrotic area in the maxillary anterior region palatal surface extending from the central incisor to the mesial aspect of the first premolar, measuring 7 cm × 4 cm []. A number of maggots were clearly seen in the necrotic area. The surrounding area was erythematous and swollen. The evaluation of a swelling was done which was accompanied by intense pain and a fetid odor. The patient had type II occlusion and multiple diastemas, making contact between the upper and lower lip impossible, in addition to having poor oral hygiene and advanced periodontal disease. Based on the history and the presence of maggots, provisional diagnosis of oral myiasis was made. Radiographic examination revealed no significant bone loss and hematological investigations were with in normal limits [Figures and ]. Under aseptic conditions, the infected site was explored thoroughly, and the wound was flushed with normal saline and irrigated with turpentine oil. Exploration of the wound revealed multiple burrows and tunnels. First, the larvae were eliminated through pressure around the lesion and the use of forceps. Second, the wound was cleaned and disinfected. Further, control is necessary to avoid further reinfestation. Cotton bud impregnated with turpentine oil was placed at the orifice of the socket for approximately 10 min. Each larva were 7–9 mm long typical creamy whitish in color, cylindrical, but tapering toward the head []. The larvae obtain their nutrition from the surrounding tissues and burrow deeper into the soft tissues by making tunnels, separating the gingiva, and mucoperiosteum from the bone. Later on, 24 maggots were manually removed with the help of tissue holding forceps and taken for entomological examination. The same procedure was repeated for two more days []. Complete oral prophylaxis involving the scaling of teeth was carried out and suturing of buccal and lingual flaps was done following complete debridement. Complete periodontal therapy was completed over the week []. Next the oral therapy was administered with tablet doxycycline 100 mg BD followed by OD for 7 days, tablet metronidazole 400 mg TID for 5 days, tablet ivermectin 3 mg BD for 5 day, chlorhexidine 0.2% mouthwash rinse 3–4 times/day. Two weeks follow-up showed complete healing of the lesion []. | Yes | t3_Eviction_mr_current |
77,997 | The presented case was a 31-year-old Chinese woman who was diagnosed with CED at the age of seven. Her antenatal and neonatal histories were uneventful. She had five siblings and she was the fourth child of her parents. Her eldest brother, who was 38 years old, developed CED symptoms at three years of age and the diagnosis was established six months following the initial presentation. Her parents and other siblings were asymptomatic; however, no investigation had been performed on them.\nAlthough her symptoms started at one year of age, due to financial constrained and poor social support, she was decided to recind the lease to avoid the court invlovement after a mutual recission agreement this year. her parents brought her to seek medical treatment at the age of seven. At first, she presented with generalized muscle wasting of all four limbs, more prominently in lower extremities. Subsequently, she experienced progressive worsening of the bone pain. She had poor appetite and failure to thrive. At the age of seven, she was brought to the hospital due to unbearable lower limb pain. Physical examination revealed severe muscle and subcutaneous fat wasting. Her body weight was below fifth percentile. She walked with waddling gait. Femur radiograph was obtained and showed irregular sclerosis of the bone. Unfortunately, the image could not be obtained for review. Before the family history was disclosed and based on the clinical features and her femur radiograph, the initial diagnosis was muscular dystrophy with chronic osteomyelitis. Later, she was reviewed in pediatric clinic and her family history was obtained. Finally, the diagnosis of CED was made based on the clinical features, radiographic findings, and family history.\nAt the age of 20, she was also diagnosed with concomitant hypogonadism and primary hypothyroidism. Her thyroid gland had not been enlarged but her free T4 level was low and thyroid stimulating hormone level was high. The symptoms of hypothyroidism resolved with initiation of L-thyroxine. Her hearing was not compromised. During follow-up, serial chest radiographs were obtained and showed typical progressive diaphyseal hyperostosis of the humerus (, and ). The rib, clavicle, and vertebrae were spared. Her left radioulnar radiograph that was taken at the age of 24 years also showed similar changes (, and ). A computed tomography of orbit was performed recently due to progressive right exophthalmos. A lateral periorbital dermoid cyst was found but she was not eager for surgical removal. Moreover, the computed tomography showed classic skull changes of CED, which included extensive sclerosis and thickening of the frontal, temporal, and petrous bones, resulting in obliteration of diploe spaces and encroachment into the frontal and sphenoid sinuses. The maxillary sinus was relatively spared (). Her orthopantomogram (OPG) showed no hyperostosis of the mandible.\nSimilarly, her eldest brother had concomitant hypogonadism and primary hypothyroidism. His clinical presentation was similar to the patient but had manifested in more severe form. He was wheelchair-bound since the symptoms started due to severe muscle wasting and bone pain. He had bilateral mixed conductive and neurosensory hearing impairment. His physical examination showed mild hepatosplenomegaly.\nThe results of their full blood counts, serum urea, electrolytes, calcium, and liver function test were in normal range, except for persistently raised alkaline phosphates (180-265 U/L). They required long-term analgesia to relieve pain. Due to the disease progression and chronic bone pain, they were not able to adapt to normal social parameters. Both of them were unemployed and required social welfare support . | Yes | t3_Eviction_mr_current |
45,323 | A nine-year-old boy was referred to the Department of Oral and Maxillofacial Radiology for the evaluation of enlarged permanent maxillary central incisors, which caused aesthetic and chewing problems (Fig. ). There was neither remarkable medical history nor family history of dental anomalies. Intraoral examination revealed permanent central maxillary incisors, with the width of 12.4 mm in the right central incisor and 12.8 mm in the left central incisor, which had incisal notches, with depth of 2.66 mm and 4.76 mm in the right and left maxillary incisors, respectively. Thermal pulp testing, percussion and periodontal probing showed no abnormalities. The patient was in the mixed dentition and the number of teeth was normal. The space between primary maxillary left and right canines had been completely filled by enlarged teeth so that both lateral incisors were also palataly displaced. For radiographic evaluation, cone beam computed tomography (CBCT) was taken (Fig. ). Each maxillary permanent central incisor had a single root with two separate canals with one orifice in the apex. On the basis of clinical and radiographic findings, diagnosis of bilateral geminated permanent central incisors was made and orthodontic and operative treatments were planned. The treatment plan was explained to the patient’s family, but they could not afford any treatment plan. They received the eviction notice from landlord and eviction is planned next few weeks. | Yes | t3_Eviction_pending |
38,502 | A 44-year-old, unemployed, married woman, living with her husband and 2 daughters was presented to the clinic with a history of mood swings and psychosis. She reported of having depressed mood, decreased energy, and a feeling of guilt and hopelessness for the last one week. She denied having any suicidal or homicidal ideations. The patient stated that she was diagnosed with bipolar II disorder at the age of 22 years; her symptoms were always mild and did not interfere with her activities. During her hypomanic phase she endorsed decrease in sleep, increased involvement in activities, high energy level, and impulsive activities (shopping spree). According to her in last few years her symptoms have increased in intensity and progressed into mania (delusions, illusions, auditory hallucinations, and obsessions). During manic period she did a lot of impulsive acts. During her most recent episode, she got obsessed with a person whom she felt she was in love with. She sent him text messages and followed him home; this continued for weeks. She was also involved in high-speed chase with cops and got into lot of trouble with law and family and had to be hospitalized. Three weeks prior to her hospitalization she was treated for her sinusitis with 60 mg oral prednisone. She reported of having a similar switch from hypomania to mania in past on using prednisone for her sinusitis. In the hospital, her steroids were tapered 5 mg every 4 days, and her symptoms were resolved. She did not report any drug allergy or any kind of abuse during her childhood. Her family history was not known as she was adopted and did not know her biological parents. She used to work full time but was currently unemployed and was also in the process of divorce. Landlord told him they will file a eviction to court soon if she still pay the rent next month. She denied smoking, abusing, alcohol, or use of any recreational drugs. Her current medications are Trazodone (150 mg QHS), Risperidone (1 mg QAM), Zyprexa (15 mg QHS), and Lithium (300 mg TID). On examination, the patient appeared her stated age and was clean with appropriate clothing. Her posture was appropriate and had normal body movement and speech. Her behavior was cooperative and had intact cognitive functions. She denied any perceptual disturbances currently, and her thought process was normal. She had a good insight about her mental illness but poor judgment as she had poor personal relationships. Laboratory workup failed to reveal any significant abnormalities. | Yes | t3_Eviction_hypothetical |
36,082 | A 12-year-old boy was referred to the Department of Pediatric Dentistry, Dicle University, Diyarbakır, Turkey for examination, evaluation and treatment of gross attrition and considerable sensitivity of his teeth. A detailed medical, dental, and social history was obtained. He was both self-conscious and unhappy as regard the appearance of his teeth. Clinical examination revealed that tissue loss affected all teeth. The enamel layer was very thin and Brown (pigmented), the cuspal structure was completely absent in the occlusal portion of the molars which were most severely affected, and enamel pit defects (pigmented stains deep) were present in the anterior teeth (Figures , , and ). However, the clinical appearance of cervical and approximal enamel seemed to be normal. It was thought that the patient likely suffered from a hypomature type of AI. The patient's occlusal vertical dimension and rest vertical dimension were assessed. The interocclusal rest space had increased because of attrition of the molars. The exposed dentin was hypersensitive. Clinical and radiographic examination of the patient revealed deep carious lesions in the maxillary four teeth, and the mandibular left first molar had been extracted because of severe attrition and caries approximately 10 months earlier. A treatment plan was developed with the following aims: to reduce the reported sensitivity of the teeth, to modify the occlusion, to restore mild crowding and masticatory function, and to improve the aesthetics. The patient was informed of the diagnosis and all treatment plans were discussed with him and his parents. He could not afford prosthetic treatment, including porcelain or ceramic restorations. Therefore, the treatment plan included placement of direct composite resin restorations in maxillary and mandibular anterior and posterior teeth. These materials were chosen because it cost less than ceramic and porcelain restorations and with the hope that it would ensure aesthetic and functional rehabilitation until the patient could cover the cost of porcelain restorations. He and his family has to vacate the house in the next month or the landlord will file an eviction to the court. Firstly, according to the manufacturer's directions maxillary and mandibular posterior teeth of patient were restored using posterior composite resin (3 M ESPE-Filtek P60, St. Paul, MN, US), after deep caries in maxillary premolar and molar teeth were removed. Later, on the maxillary and mandibular anterior teeth, a 0.5 mm facial reduction was prepared for direct composite resin laminate veneers. In addition, the finish line at the proximal and cervical aspects of the teeth preparations was extended, and a rounded finish line throughout was prepared for the restoration. All teeth preparations were completed without sharp line angles. Maxillary and mandibular anterior teeth of the patient were restored using composite resin (3 M ESPE-Filtek Supreme XT Universal, St. Paul, MN, US) (Figures , , and ). The patient was recalled at 2-month intervals. The 24-month recall clinical and radiographic examination revealed no pathology associated with the rehabilitation, and the patient's aesthetic and functional expectations were satisfied (). | Yes | t3_Eviction_hypothetical |
105,589 | On December 13, 2016, a 30-year-old Han Chinese woman in 34+6 wk of pregnancy was admitted to the Department of Obstetrics, First Hospital of Jilin University, due to premature rupture of the fetal membrane and regular contractions for 7 h. The patient reported no menstrual abnormalities. Her last menstrual period was on April 13, 2016, and the expected delivery date was January 20, 2017. She did not undergo regular prenatal examinations during her pregnancy. The patient reported a development delay in learning to walk at the age of 6 years and had poor exercise endurance. She usually experienced troubled breathing, dizziness, and heavy perspiration after fast walking or running. However, she had not undergone systematic diagnostic procedure and had not been diagnosed officially. The patient was unemployed, and had no history of smoking or drinking. No pertinent family history was presented. A physical examination upon admission revealed that her general condition was poor (temperature: 36.5 °C, pulse: 126 beats per min, respiratory rate: 28 breaths per min, blood pressure: 153/78 mmHg, oxygen saturation: 83%), and she exhibited cyanosis and shortness of breath. An abdominal examination revealed that she was in the third trimester, and the fetal heart rate was 145 beats per min. Pelvic examination revealed that her cervix was dilated to approximately 10 cm. The patient’s serum troponin level was normal, as were her liver function, renal function, and routine blood test results. No imaging examination was performed in the Department of Obstetrics because of the emergency situation. She was transferred to the labor room immediately. Considering her low oxygen saturation, a heart disease could not be ruled out. Therefore, perineal incision and forceps were used to assist the vaginal delivery and shorten the second stage of labor. A pre-term female neonate was delivered vaginally. Fentanyl (0.002 mg/kg) was slowly intravenously injected to relieve her pain and reduce the cardiac load. However, she continued to experience shortness of breath. Her cyanosis worsened, her heart rate was 120 beats per min, and her blood oxygen saturation ranged from 80%-85%. She was transferred to the intensive care unit immediately. The patient was cyanotic and lacked spontaneous breathing when admitted to the intensive care unit. Immediately, endotracheal intubation was performed and the patient was put on ventilator-assisted respiration. Although, physical examination revealed a body mass index of 15.6, all other findings were normal. Recovery of spontaneous breathing was observed soon after intubation. Her oxygen saturation reached 100% with low respiratory support parameters. Tracheal intubation was removed on the second day postpartum. Her cardiac color Doppler ultrasound and electrocardiography were normal. A careful physical examination revealed that she had certain characteristic facial features (Figure), most notably a thin, elongated face, and a high arched palate. Moreover, muscle volume was less in the limbs, trunk, face, and neck (Figure), and she exhibited scoliosis with a waddling gait. Computed tomography of the chest (Figure) revealed scoliosis. Considering the clinical manifestation and physical examination of the patient, motor neuropathy and respiratory muscular disease could not be excluded. Electromyography suggested a myopathic process (Figure). Biopsy of the left bicep brachia revealed a predominance of type 1 muscle fiber atrophy in the absence of other structural abnormalities, such as that of the rods or cores (Figure). Our patient's parents and brothers exhibited no signs of CM. They declined to undergo genetic testing. Eviction is planned for the next few month if the tenant sill not pay the rent. | Yes | t3_Eviction_hypothetical |
53,683 | A 74-year-old male with a history of mild cognitive impairment presented to the emergency department with failure to thrive and generalized weakness of three weeks duration. He was having difficulty swallowing which he related to a poorly fitted denture. He had thirty pounds of unintentional weight loss in the last three months due to loss of appetite. He was been notified has to vacate the house before next month or the landlord will file eviction to the court. His past medical history was significant for diabetes mellitus type II, hypertension, major depressive disorder, chronic pain syndrome, and hepatitis C. His social history was significant for 12.5 pack-year smoking and drinking (two to three glasses of wine/day). He denied any utilization of recreational drugs. In the emergency department, his vital signs were, BP-104/59 mmHg, HR-97 bpm, respiratory rate-14/minute, temperature-97.4 °F, and oxygen saturation was 99% on room air. He weighed 40 kg, and his BMI was 13.84 kg/m2. On physical examination, he was alert, oriented, and appeared weak and malnourished. The ill-fitted complete maxillary denture was removed. The oral cavity examination revealed a large (3 × 2 cm2) defect with an erythematous border that encompassed the mid-palatal structures and emanated from the hard palate into his nasal cavity (Figure ). There was no discrete mass or ulcer and mucosa surrounding this defect appeared normal. On palpation, the lesion was non-tender without any palpable lymph node on the head and neck examination. His lungs, heart, neurological, and abdominal examinations were unremarkable. Laboratory data at admission showed Hb-11.7 g/dl, WBC’s-9.6 K/CMM, and platelets-190 K/CMM. The chemistry panel (BMP) was within the normal range. AST-23 U/L, ALT-25 U/L, and serum alkaline phosphatase were 114 U/L. Auto-immune work-up including anti-dsDNA, anti-proteinase-3 antibodies, myeloperoxidase (MPO) antibodies were negative. The patient was managed conservatively, with nutritional supplementation and supportive care. Contrast-enhanced CT of the neck demonstrates enlarged level 2A lymph nodes bilaterally (Figure and 2B), corresponding to increased fluorodeoxyglucose (FDG) avidity on PET CT (Figure ). A biopsy of the palatal lesion was performed, which showed SCC (well-differentiated), with parakeratosis, acute, and chronic inflammation (Figure ). Immunohistochemistry by p16 shows diffuse nuclear and cytoplasmic staining of well-differentiated SCC (Figure ). PD-L1 test showed a combined positive score of 10-15. CT chest, abdomen, and pelvis were negative for metastasis. NM bone scan showed radiotracer uptake in paranasal sinuses/facial bones. PET scan showed diffuse FDG activity in the hard palate, mildly hypermetabolic cervical, pretracheal, subcarinal, and left hilar nodes with minimal FDG activity. A diagnosis of locally advanced (stage IVa) oral cavity SCC was made. The patient was evaluated by a multidisciplinary team including an oncologist, head and neck surgeon, maxillofacial surgeon, radiation oncologist, and nutritionist for further management. The patient underwent prosthetic rehabilitation. A palatal obturator (prosthesis) was placed to improve his speech, eating, and prevent regurgitation. The patient opted for palliative care and did not want to pursue further treatment. He was discharged home. | Yes | t3_Eviction_hypothetical |
62,444 | A 58-year-old male with a history of hypertension and prior venous thromboembolism presented to the emergency department (ED) for 1 week of weakness and fatigue. The landlord plan to file for eviction next month if the tenant still not leave.
He denied any hemoptysis, dyspnea, chest pain, headache, nausea, and vomiting. Besides a heart rate of 113 bpm his physical exam was normal. His past medical history included type II diabetes. His past surgical history was significant for an infrarenal IVC filter placement 15 years ago that was still in place. He was unsure as to why it was initially placed. He had no known allergies and took atenolol, lisinopril, and metformin at home. He was not taking any oral anticoagulants. He had no family history of malignancies and bleeding disorders. While in the ED the patient became unresponsive and ACLS was initiated and lasted for 11 minutes. The patient was intubated, resuscitated, and transferred to the intensive care unit. While in the ICU it was noted that the patient's hemoglobin dropped from 12.3 gm/dL to 6.8 gm/dL. [ | Yes | t3_Eviction_hypothetical |
65,006 | A 25-year-old Caucasian male with no significant past medical history was admitted to the pulmonary service for further workup of hemoptysis in May of 2015. The patient initially presented to an outside hospital in 2014 with three episodes of frank hemoptysis that was two to three tablespoons in quantity. It was associated with shortness of breath on exertion and cough that was productive with yellowish sputum. During that admission, he underwent a CT scan of the chest that showed a 8 cm lobulated mass in right lower lobe with right hilar nodes. He underwent bronchoscopy with mediastinoscopy due to the concern for malignancy. There were no endobronchial lesions seen per the report and pathology showed squamous metaplasia with ulceration. He left against medical advice (LMA) prior to completion of further workup.
The patient was seen in our emergency room in May 2015 with a cough with blood-tinged sputum that has gotten worse since his previous admission. He also endorsed 10-pound weight loss and poor appetite. He denied any fever, chills, foul smelling sputum, or recent travel outside the country. He was currently unemployed and smoked one pack of cigarettes daily for last five years. The landlord plan to serve the eviction due to the rent was not received. There was no significant family history.
Informed patient consent was obtained for his treatment. The patient was started on broad-spectrum antibiotics and underwent a CT scan of the chest that showed an irregular mass-like consolidation measuring 9.5 x 5.0 cm in the right lower lobe with adenopathy and right lower lobe bronchiectasis (Figures -). He also underwent a PET/CT that was significant for an FDG-avid mass in the right lower lobe demonstrating an standardized uptake value (SUV) max of 4.5 (Figure ).
The patient underwent flexible bronchoscopy that was remarkable for copious purulent secretions in all large airways with friable mucosa (Figure ) and marked mucosal irregularities in the right lower basal segments. Once the secretions were cleared, a gray-colored solid foreign body (approximately 1.0 x 0.5 cm) in right lower lobe was seen that was removed with toothed forceps (Figure ). Pathology was remarkable for non-viable foreign material and underlying submucosa with diffuse lymphoplasmacytic infiltrate admixed with neutrophils, eosinophils, and a few granulomas with no malignancy features.
On repeated questioning, the patient admitted to habitual chewing of plastic objects and recalled one episode in 2009 when he may have fallen asleep while chewing on a plastic object. He was given antibiotics for two weeks and was discharged home [INSERT HERE] with a plan to repeat a CT scan in six to eight weeks. However, he was lost to follow-up again. We hypothesize that this episode in 2009 may have caused the unintentional aspiration of the foreign body into the lungs, which the patient was unaware of. This occult foreign body caused foreign body granuloma resulting in a tumor-like mass with intense FDG avidity mimicking malignancy . | Yes | t3_Eviction_hypothetical |
66,985 | The patient was a 45-year-old man who presented with a headache for 3 months which was progressive and had been intolerable for 2 weeks. However, the patient was a football player with good health. There was no such family history and family members were perfectly well. There were no other clinical symptoms reported by the patient. He has to leave the house in the next month or the landlord will serve an eviction notice. The patient was advised to do CT-scan and MRI. Interestingly both CT-scan and MRI revealed brilliantly enhancing left lateral ventricular lesion with unilateral hydrocephalus (). T1 Image axial view postcontrast () and precontrast film () were also examined. T1 image of coronal view in postcontrast film was also evaluated (). T2 image in sagittal view () also found the SOL. Flare image () was examined as well. All other investigations were within normal limit. Then the patient was advised for surgery for removal of the lesion. In this context, left parietal craniotomy was performed with total removal of the lesion through intraparietal approach. Reversal from GA and the postoperative period was uneventful and the patient had got rid of clinical symptom completely after surgery. The tumor was well defined preoperatively and was removed under microscopic surgery meticulously. The patient was very poor to bear the cost of postoperative CT-scan and hence it was not done. The biopsy was sent for histopathological examination. The lesion was nearly spherical measuring 3.0 cm + 2.5 cm, whitish, and firm. There was no evidence of necrosis. Microscopy revealed multicystic appearance with cyst lined by columnar epithelium with apical mucin. Few goblet cells were seen. Few areas had shown pseudostratified lining epithelium with nuclear hyperchromasia, nuclear enlargement, and increased mitosis. There was no evidence of stromal invasion. The mucinous material was seen within the lumen. Hemosiderin laden macrophages were present in the stroma. It was confirmed as a lateral ventricular enterogenous cyst. Then the patient was well in around one year. After about one year of the surgical removal of the lesion, there was a recurrence of a headache whose intensity was more than the previous one. Then the patient was advised to do a CT-scan which revealed lesion of the same pattern in the same location as before (). The patient was reexplored surgically and the tumor was removed completely through the same route and histopathology was again revealed it as a case of the enterogenous cyst. Again the total removal of the lesion from the brain was confirmed by postoperative CT-scan. Then the patient was advised for radiotherapy. After completion of radiotherapy, the patient was perfectly well at 13th postoperative month (). | Yes | t3_Eviction_hypothetical |
94,035 | A 55-year-old unemployed Hausa man presented to us with 24 hours history of a self-inflicted anterior neck wound from a suicidal attempt. He has 12 children from 2 wives and the unavailability of funds to cater for his family was the reason he gave for attempting to take his life. Landlord told him they will file a eviction to court soon if he still pay the rent next month. He denied substance abuse. No family history of psychiatric disorder. No history of self-injury or poisoning. He was discovered by his children in his bedroom in a pool of blood with a slit throat.\nExamination revealed a pale middle aged man who was not dyspnoeic with a 14 cm anterior neck laceration exposing his hypopharynx and larynx (Figure ). Tetanus prophylaxis and parenteral antibiotics were given. He was transfused 2 units of whole blood and given tracheostomy. His wound was repaired under general anesthesia administered via the tracheostomy tube. Nasogastric tube was inserted intraoperatively following repair (Figure ). He was commenced on parenteral ciprofloxacin, metronidazole and pentazocine postoperatively. Stitches were removed and decannulation process started on the 5th postoperative day and completed alongside nasogastric tube removal uneventfully on the 7th postoperative day.\nHe started having psychiatric care and supervision immediately postoperative and was given. Follow up in the clinic has been uneventful for 6 months after discharge on the 14th postoperative day. | Yes | t3_Eviction_hypothetical |
93,618 | V.F (40-year-old male) was brought to our hospital by police with a reception order from the court after a complaint was made to the police by his sister and his neighbors. V.F was diagnosed to be suffering from paranoid schizophrenia for last 4 years for which he had received no treatment. He believed that people in his locality were his enemies and would kill him and his family. He had been unemployed and been a homeless for the last 4 years. On further evaluation, he was also diagnosed as suffering from anti-social personality disorder along with alcohol abuse. He stopped his wife and children from going out of the house. He stopped his children from going to school. He would guard, whole day, the gate of his house. Over the last 1 year, his wife and children also started believing that the people in their locality wanted to kill them and stopped any kind communication with them. The delusional context was same in all involved family members. The wife and the children had no past history of psychiatric illness but showed dependent personality traits. V.F had family history of psychiatric illness in his mother, details of which could not be ascertained. He was not suffering from any medical illness. All the family members were intimately associated; the family showed growing social isolation from the social network of neighbors and relatives. None of the family members were employed. The onset of symptoms in all the other family members was 3 years after the symptoms in the primary patient, V.F, started. The primary patient demonstrated most of the other criteria for schizophrenia according to DSM-IV, while other family members showed most features of shared psychotic disorder. V.F. was started on antipsychotic medication, tablet Risperidone 2 mg twice per day, which was increased to 6 mg/day in two divided doses, along with electroconvulsive therapy. The wife and children visited the patient only twice during the course of his admission in the hospital which lasted around 2 months. They refused any kind of treatment but their delusional beliefs weakened over the 2 months period. The patient improved and was discharged on tablet Risperidone 6 mg/day, as the family did not want to further keep him in the hospital. Following discharge from the hospital, the family refused to live separately from the patient. The patient did not comply with treatment and was lost to follow up after four outpatient visits. | No | t1_Homelessness |
92,597 | This is a case of a 65-year-old Jewish male who presented to our hospital complaining of a two-week history of sero-sanguineous oozing coming from a healing surgical wound overlying an ICD that had been implanted sixteen days prior to the day of admission at a different medical center. No purulent discharge was seen. The area became increasingly painful. The patient denied any fevers, chills, palpitations or other cardiovascular symptoms on admission. Vital signs were as follows: Temperature of 98.4°F, Blood pressure of 105/64 mmHg, Heart rate of 60 beats per minute, Respiratory rate of 14 breaths per minute and Oxygen saturation of 98% on room air. Physical examination revealed an eight-centimeter irregularly oval, warm, swollen, erythematous and tender area on the left anterior-superior chest wall. No local ulcers or new heart murmurs were noticed. Poor dentition, together with the presence of disheveling appearance was appreciated. [\nPast medical history was positive for non-ischemic dilated cardiomyopathy, congestive heart failure (NYHA class III), atrial fibrillation, essential hypertension and a recent syncopal episode. The patient had no history of alcohol, tobacco or illegal drug abuse. He was a retired messenger since 2004 and lived in a shelter. No family history of cardiomyopathy or oncologic diseases was noted. \nAdmission laboratory findings revealed mild leukocytosis together with mild normocytic normochromic anemia (). An electrocardiogram showed atrial paced rhythm at 60 beats per minute, a QRS complex of 102 msec and a QTc interval of 480 sec, no signs of ischemia were recorded. His home medications included Warfarin, Carvedilol, Lisinopril and Simvastatin.\nProvidencia rettgeri grew in two sets of deep wound cultures, one set of superficial wound cultures, one set of peripheral blood cultures obtained on the day of admission as well as from the culture of the removed device. The antibiotic resistance pattern was similar in all the cultures (). A trans-esophageal echocardiography did not reveal vegetations or signs of endocarditis.\nThe entire implanted system, including the cardiac leads of a dual chamber cardioverter-defibrillator, Medtronic®, model D224DRG, Secura DR was removed on day two of admission. The wound was left opened, and dry to wet dressings were applied locally. Resolution of the infection was seen after the patient received a four-week course of intravenous Cefepime two grams every twelve hours, subsequent surveillance blood cultures revealed no growth and second intention healing of the surgical wound ensued. An external defibrillator vest was initially placed and as soon as the antibiotic regimen was completed a new dual chamber cardioverter-defibrillator was placed on the right side of the thoracic wall. The patient was subsequently discharged with adequate follow-up. | No | t1_Homelessness |
90,201 | A 68-year old Russian female, who is living on the streets, was brought the emergency department by paramedics with the complain of sudden onset left sided retrosternal squeezing chest pain radiating to the left shoulder and the back with a intensity of 7/10 associated with shortness of breath. The pain began while she was mopping the floor. It was the first time patient had experienced such pain. She has no significant past medical or a family history of coronary artery disease and was not on regular medication except for occasional over the counter pain medications.\nUpon arrival she was found to have blood pressure of 80/40 mm Hg, heart rate of 56 beat/min, respiratory rate of 24/min and a temperature of 98°F, oxygen saturation of 98% on room air. On examination S1 S2 was regular no murmurs appreciated and basal rales were noticed and the rest of the physical examination was normal The Electrocardiogram (EKG) done on arrival showed ST-elevation in leads V3–V5 with T-wave inversions in leads V4–V5 (Figure ) Creatine phosphokinase (CPK) with mass, index and Troponin-I levels were only mildly elevated with a peak CPK of 415 U/L (10–225), CKMB mass of 20 ng/ml (0–10), CK index of 4.8 (0.0–3.0) and a peak Troponin I of 0.6 microg/L (< = 0.1). An initial diagnosis of anterior wall ST elevation myocardial infraction was made; aspirin 162 mg orally with morphine 2 mg and phenergan 12.5 mg intravenous was given. Beta blockers were held as the patient was hypotensive and bradycardic, she was given a fluid challenge with 1 liter of normal saline over half an hour. The echocardiogram (Echo) done in the emergency room revealed hypokinesia of the anterior wall, septum, and the apex, left ventricular ejection fraction of 35–40%, poorly visualized left ventricular outflow tract (LVOT) and mitral regurgitation of unknown severity. [INSERT HERE]\nWith the ongoing chest pain, EKG changes, positive cardiac enzymes and the echocardiographic findings patient was thrombolysed with 2 doses of Retavase, 30 minutes apart followed by intravenous heparin and transferred to the coronary care unit. As there was no improvement in blood pressure (70/40 mmHg) with a fluid challenge and after 3 liters of normal saline infusion and worsening Shortness of breath, Dopamine infusion was started to improve the blood pressure. Three hours later as there was no improvement of the blood pressure, worsening pulmonary edema and drop in oxygen saturation on nasal cannula prompted the decision to intubate and place an intra-aortic balloon pump. \nShe was subsequently transferred to hospital with invasive cardiac catheterization facilities for emergency cardiac catheterization Coronary angiography revealed non obstructive coronary arteries (Figure ). Left ventriculogram showed systolic dysfunction of the left ventricular apex and mid-ventricle, with hyperkinesis of the basal left ventricular segments and LVOT blood flow gradient of 58 mmHg and a 2+ mitral regurgitation (Figure ). \nOver the next few days, patient's blood pressure improved and she was extubated and the balloon pump was removed. Patient was asymptomatic and physical examination was normal. Her EKG returned to normal and repeat Echo was entirely normal with no wall motion abnormalities, no LVOT obstruction and no mitral regurgitation and an ejection fraction of 60%. Patient was discharged on Aspirin 81 mg daily and Metoprolol 25 mg twice a day. Patient was followed up for a period of one year there was no recurrence of her clinical symptoms and the repeat echocardiogram as well as stress echo was normal. | No | t1_Homelessness |
97,706 | A 47-year-old woman with no significant medical history nderwent upper gastrointestinal endoscopy as part of a comprehensive medical examination for suspected gastric submucosal tumor. She lost her home and is staying in a homeless shelter temporarily. Contrast-enhanced abdominal computed tomography (CT) revealed the presence of a gradually enhancing lesion (63 × 56 mm) in the splenic hilum (Fig. ). Abdominal ultrasonography revealed an irregular hypoechoic lesion in the spleen. Although splenic fibrotic hamartoma was suspected, malignancy could not be ruled out. Since the risk of bleeding and dissemination was present in case of malignant tumor, ultrasound-guided needle biopsy was not recommended. We recommended that magnetic resonance imaging (MRI) and 2-[18F]-fluoro-2-deoxy-D-glucose − positron emission tomography (FDG-PET) should be performed, but the patient refused.We also suggested that she undergo CT several months later, but she chose to undergo splenectomy. Therefore, we performed laparoscopic splenectomy after obtaining patient consent. The surgical procedure was as follows. The patient was administered general anesthesia, positioned in the right semi-lateral position, and 4-port laparoscopy was performed to identify the tumor in the splenic hilum (Fig. ). We cut the greater omentum, opened the omental bursa, and carefully dissected the gastrosplenic ligament. [INSERT HERE] It was difficult to secure the operative area of the upper spleen due to the tumor in the splenic hilum. However, by dissecting the splenic artery and vein at the lower spleen, the operative area of the upper spleen could be secured. We dissected the splenic artery and vein using an autosuturing device. After putting the spleen in a bag, we made a small incision in the umbilicus and removed it. The procedure duration was 134 min, and limited bleeding was observed. The postoperative course was uneventful, and the patient was discharged from the hospital 8 days after surgery. [INSERT HERE] The resected spleen was 19.0 × 8.4 × 5.6 cm and weighed 240 g; the splenic hilum was occupied by an unencapsulated nodular lesion having dimensions of 6.2 × 4.6 × 5.1 cm. The lesion was firm and grayish to whitish tan in color (Fig. ). Immunohistopathological examination revealed extensive fibrous connective tissue and collagen fiber bundles. Furthermore, a nodular cluster of blood vessels, erythrocytes, and slit-like blood vessel spaces were observed. Three types of vascular components were found: sinusoid veins (CD8+/CD34–/CD31+), cord capillaries (CD8–/CD34+/CD31+), and small veins (CD8–/CD34–/CD31+), which were intermixed and in high numbers. CD68-positive cells were accumulated at the center of the lesion; however, D2–40-positive cells were absent. Therefore, the lesion was diagnosed as SANT (Fig. ). | No | t1_Homelessness |
143,705 | A 50-year-old male patient was reported to the Department of Oral Medicine and Radiology with the complaint of pain and swelling on the right side of the face since 15 days. Patient noticed an ulcer on the right buccal mucosa 4 months ago which progressed to involve the complete right buccal mucosa, including vestibule and alveolar ridge. Severe pain and burning sensation was experienced by the patient since past 15 days. Patient gave a history of exfoliation of two teeth from the same region, 2 weeks ago. He also noticed two extraoral wounds with blood and pus discharge since then. Past medical and family history was not significant.
On extraoral examination, there was diffuse swelling on the right side of the face, extending vertically from right inferior orbital rim to the inferior border of mandible and horizontally from right ala of the nose to angle of mandible. Two extraoral ulcers were seen [] with blood and pus discharge. The overlying skin was reddish in color. The swelling was firm and tender on palpation. Few maggots were seen coming out of the ulcers. Bilateral submandibular and submental lymph nodes were enlarged, fixed, firm, and tender.
On intraoral examination, an ulceroproliferative lesion was seen involving the complete right buccal mucosa, vestibule and extending to the alveolar ridge. Profuse bleeding was seen from the lesion. Orthopantomograph showed irregular bone destruction extending from 44 to 48 and soft-tissue shadow was seen, which were suggestive of a malignant lesion []. Depending on the history, clinical and radiographic features and presence of maggots, the provisional diagnosis of malignant tumor with Myiasis infestation was made.
Mechanical removal of larvae was done using turpentine oil along with surgical debridement of necrotic tissue []. The wound was debrided for next 5 consecutive days and all of the maggots were removed. Systemic antibiotics, Augmentin 625 mg (amoxicillin + clavulanic acid) 3 times a day for 7 days, metronidazole 400 mg 3 times a day for 5 days and 0.2% chlorhexidine antiseptic mouthwash, were prescribed for 7 days. The incisional biopsy was done on the 5th day and histopathologically, the section showed, stratified squamous epithelium with proliferation. The connective tissue was invaded by tumor, showing malignant epithelial cells with large hyperchromatic pleomorphic nucleus and a moderate amount of cytoplasm. Keratin pearl formation was also noted at places. The stroma showed dense inflammatory cells predominantly lymphocytes and plasma cells. Overall features were of well-differentiated squamous cell carcinoma [].
The patient was referred to Oncology Department of the same institute for radiotherapy. Patient had undergone 15 cycles of radiotherapy and did not return for further treatment and follow-up. The patient was experiencing homelessness. | No | t1_Homelessness |
55,419 | A 39-year-old female presented with severe excruciating left leg pain to gentle touch and left leg swelling. She had been diagnosed and treated conservatively with warfarin elsewhere for extensive proximal left lower extremity DVT and a small right lower lobe pulmonary embolism a week before. The patient was hemodynamically stable but was uncomfortable due to severe pain. Her left leg was almost twice the size of her normal right leg. Physical examination showed pitting edema, focal bluish discoloration over the anterior lower shin, visible varicosities, and peripheral pulses detectable only by Doppler ultrasonography. She had exquisite tenderness to palpation in the left leg and pain with passive motion. However, she was able to move her legs. Her body mass index was 26.8 kg/m2.\nHer past medical history was not significant and she denied any history of smoking or illicit drug use. She was homeless and had a history of two spontaneous miscarriages in the past with no obvious cause, but she denied a history of any medications including oral contraceptive pills. Family history of hypercoagulable states was absent. Laboratory values including renal function tests and lipid profile were unremarkable except for an international normalized ratio (INR) of 1.6. Human immunodeficiency virus and hepatitis C virus serology were negative. Venous Doppler study showed a large clot extending from the left common iliac vein to the common femoral vein and the popliteal vein. CT venogram of the lower extremity confirmed the clot and showed a small amount of thrombus at the inferior vena cava (IVC)/left common iliac vein junction. The above findings suggested the diagnosis of MTS (Figures -).\nAs she was a suitable candidate for mechanical thrombolysis and thrombectomy, she underwent catheter-directed mechanical thrombolysis and thrombectomy of the complete left lower extremity venous system and the left common iliac vein on the third day of admission. She was monitored in the intensive care unit postoperatively and had no complications. On the next day, angioplasty was done for high-grade focal narrowing (>90%) of the left common iliac vein and the external iliac vein, with near-complete resolution post-treatment (Figure ) and no post-procedure complications. After an additional three days of hospital stay, she has discharged on oral apixaban 10 mg twice a day for one week and outpatient follow-up with a hematologist. After the first week, she was kept on apixaban 5 mg twice a day. One month after discharge, she was readmitted for bleeding and a left mid-foot hematoma, which was evacuated on the bedside. She had no recurrence of thrombosis on six months follow-up (Figure ). Thereafter, she was lost to follow-up. | No | t1_Homelessness |
62,444 | A 58-year-old homeless male with a history of hypertension and prior venous thromboembolism presented to the emergency department (ED) for 1 week of weakness and fatigue. He denied any hemoptysis, dyspnea, chest pain, headache, nausea, and vomiting. Besides a heart rate of 113 bpm his physical exam was normal. His past medical history included type II diabetes. His past surgical history was significant for an infrarenal IVC filter placement 15 years ago that was still in place. He was unsure as to why it was initially placed. He had no known allergies and took atenolol, lisinopril, and metformin at home. He was not taking any oral anticoagulants. He had no family history of malignancies and bleeding disorders.\nWhile in the ED the patient became unresponsive and ACLS was initiated and lasted for 11 minutes. The patient was intubated, resuscitated, and transferred to the intensive care unit. While in the ICU it was noted that the patient's hemoglobin dropped from 12.3 gm/dL to 6.8 gm/dL. | No | t1_Homelessness |
83,566 | A 43-year-old homeless male presented with several weeks of weight loss, bilateral burning foot pain, and overall weakness that had progressed to an inability to walk. The past medical history was largely unknown but included admission to a different hospital two years prior with acute kidney injury secondary to rhabdomyolysis, with a serum creatinine of 1.5 mg/dL on discharge. The social history was significant for crack-cocaine use. On admission, he appeared cachectic and had a temperature of 38.7°C. On the neurological exam, he had impaired soft touch sensation bilaterally up to the ankles and diffuse weakness. There were no skin abnormalities seen.\nThe creatinine on admission was 3.93 mg/dL, and the BUN was 55 mg/dL (upper limit of normal is 1.0 mg/dL and 25 mg/dL, resp.). A globulin gap was present with a total protein of 6.7 g/dL and albumin of 1.4 g/dL. Urinalysis demonstrated moderate protein and blood, with a spot protein-creatinine ratio of 1 : 55 mg/mg (upper limit of normal is 0.11 mg/mg). There was no peripheral eosinophilia. Microscopic urinalysis showed granular casts but no red blood cell casts. His urine tested positive for eosinophils. Cocaine metabolites were found on urine toxicology. HIV, anti-nuclear and anti-glomerular basement membrane antibodies, RPR, and hepatitis B and C serologies were negative. There were no abnormal bands on serum or urine protein electrophoresis. ANCA were strongly positive at 1 : 5120 (upper limit of normal is less than 1 : 20) with a perinuclear staining pattern and myeloperoxidase reactivity at 76 AU/mls (upper limit of normal is less than 19 AU/mls). Kidney biopsy specimen had a total of 21 glomeruli, out of which only two were globally sclerotic. The majority of glomeruli showed pauci-immune necrotizing crescentic glomerulonephritis (). A prominent plasma cell-rich tubulointerstitial nephritis was also present.\nBased on his laboratory findings and renal biopsy, a diagnosis of microscopic polyangiitis was considered, but levamisole-induced ANCA vasculitis remained a likely possibility given his history of cocaine use. The presence of interstitial nephritis on biopsy was felt to explain the eosinophils in his urine, a finding previously reported in cocaine users []. He was treated with pulse methylprednisolone 1000 mg for three days and 600 mg of IV cyclophosphamide. His creatinine peaked to 7.21 mg/dL during hospitalization but stabilized at 6.25 mg/dL after treatment. The patient was counseled on abstaining from cocaine and was discharged on 40 mg of prednisone per day with instructions to follow-up for monthly cyclophosphamide injections at renal clinic.\nThe patient was readmitted one month later with increasing lower extremity swelling and pain. He had been off prednisone since discharge and had ongoing crack-cocaine use. Renal function had declined, reaching serum creatinine of 8.8 mg/dL. He was treated with cyclophosphamide and prednisone, and his fluid status and electrolyte abnormalities were corrected. Renal function did not improve with treatment, and hemodialysis was initiated. | No | t1_Homelessness |
17,565 | A 55-year-old male was referred to a gastroenterologist for a persistent mild transaminitis of an AST in the 40s and an ALT in the 80s. He had a history of hyperlipidemia, obesity with a BMI of 38, and sleep apnea. He took simvastatin 80 mg daily with no antiplatelets or anticoagulants. He consumed about 3 to 4 alcoholic beverages per week, and he had no family history of cirrhosis. Viral serologies were negative, and iron and copper studies were normal. Serologies for autoimmune hepatitis, primary biliary cirrhosis (PBC), and primary sclerosing cholangitis (PSC) had been normal. He was referred to a radiologist for an ultrasound- (US-) guided biopsy. His INR was 1.1, and his platelets were 236,000 cells/μl. A 17 G needle was used for anesthesia and a 14 G needle for sampling. After the procedure, he had a collagen thrombin slurry embolization of the tract. Later that day, he presented with right upper quadrant pain, transient tachycardia to the low 100 s, and tenderness in the right upper quadrant without rebound. Studies revealed a leukocytosis of 13,900 cells/μl, a total bilirubin of 1.2 mg/dl, and a CT of the abdomen and pelvis with intravenous (IV) contrast revealed a 2 cm subcapsular fluid collection which was attributed to a hematoma (Figures and ). He was admitted for 24 hours of observation with improved pain control and was discharged. He returned 4 days later with worsening pain, shortness of breath, and loss of appetite. He was febrile to 102.3 F and tachycardic to the 110 s and was tender without peritoneal signs in the right upper quadrant. He had a persistent leukocytosis, and his total bilirubin increased to 3.3 mg/dl. A CT with IV contrast was repeated with enlargement to 12 cm of his subcapsular fluid collection (Figures and ). The next day, he underwent percutaneous drainage with return of 20 m of green bilious fluid, and a pigtail catheter was left in place after the diagnosis of biloma was confirmed. The same day he was transferred to a facility with ERCP (endoscopic retrograde cholangiopancreatography) capabilities which demonstrated a bile leak from a small, distal duct of the right lobe which was stented with a 5 cm, 10 F plastic stent of which no images were recorded. He was discharged the following day on a week of amoxicillin/clavulanate. At a clinic follow-up a week later, his pain had improved, his vitals had normalized, and his drain output had diminished. The drain was removed, and he was arranged a follow-up 6 weeks later for stent removal. The patient reported issues with inadequate housing, including a lack of reliable heating and exposed wiring, contributing to his overall health concerns. | No | t1_InadequateHousing |
28,830 | A 57-year-old healthy female underwent colonoscopy in the context of a positive fecal immunohistochemistry test (FIT) of 77 ng/mL. Her medical history was only significant for a remote caesarean section. Her family history was significant for her father having colonic polyps at the age of 70. The patient also endorsed occasional NSAID use. The patient had used Bi-Peglyte solution for bowel preparation. The patient reported living in inadequate housing conditions, with issues related to plumbing and heating that could affect her overall health. The patient was sedated before and during the procedure with a total of 3 mg of midazolam and 100 mcg of fentanyl. CO2 was used to insufflate the colon. The colon was quite tortuous and required repositioning of the patient on to her back and right side. Application of counter pressure was also used to reach the cecum. Bowel preparation was suboptimal, and fecal material clogged the endoscope numerous times. Extensive lavage and suction were required during withdrawal. A 1.2 cm pedunculated polyp in the descending colon was injected with methylene blue and completely removed as 2 pieces by hot snare polypectomy. Withdrawal time was 15 minutes. Overall, the patient tolerated the procedure well. Pathology of the polyp demonstrated a tubulovillous adenoma with low-grade dysplasia. The patient subsequently presented to the emergency department (ED) 2 days after colonoscopy with severe abdominal pain but no bleeding or diarrhea. Initial bloodwork was unremarkable other than an elevated lactate of 5. A CT abdomen with IV contrast demonstrated diffuse large bowel thickening with severe involvement of the sigmoid and small volume of pelvic ascites (). There was no hemoperitoneum, pneumoperitoneum, or bowel obstruction. The patient underwent an urgent flexible sigmoidoscopy. Starting at the rectosigmoid junction, there were patchy, dusky areas of mucosa with submucosal swelling and erythema but no frank ulcerations (). The endoscope was only advanced to the midsigmoid, and biopsies were not taken due to the fear of inducing more complications. The proximal extent of the changes was not determined. A diagnosis of IC was made. She ultimately deteriorated hemodynamically and required placement of central venous access for vasopressors. She was then admitted to the high acuity unit (HAU) and monitored in anticipation of possible colectomy. Interestingly, her blood cultures were positive for group A Streptococcus (GAS). This bacteremia was thought acquired due to an occupational hazard and likely unrelated to her IC. She stated that she had experienced symptoms of pharyngitis several weeks ago. A CT of the neck ruled out an abscess and an echocardiogram ruled out infective endocarditis. Over the next few days, the patient's abdominal pain subsided, and she recovered hemodynamically without the need for surgery. She was discharged 6 days later with oral antibiotics for her bacteremia. | No | t1_InadequateHousing |
120,173 | A 53-year-old woman was transferred to our facility with a left breast wound demonstrating signs of skin necrosis, erythema and severe pain. Past medical history included hypertension, asthma and obesity with a BMI of 41 kg/m2. She reported a current smoking history. She denied a family history of breast cancer and never had a mammogram. The patient reported living in an older home with inadequate heating and plumbing issues that have not been addressed. The patient was seen three days prior at an outside facility for an abscess overlying the lower inner quadrant of the left breast. An incision and drainage was performed. The wound was packed, and the patient was discharged home with Sulfamethoxazole-Trimethoprim. She returned to the same facility two days later with worsening erythema, pain and malodorous drainage from the previous incision and drainage site. She had a heart rate of 111 bpm and a blood pressure of 96/53 mmHg. A CT scan of the chest demonstrated gas in the soft tissues of the left breast and anterior chest wall with no evidence of abscess formation. The patient was given one dose of Vancomycin and Piperacillin-Tazobactam, intravenous fluids, and transferred to our facility. On exam, her left breast and sternum were erythematous, swollen, and tender to palpation. Purulent, foul smelling material was expressed from the prior incision site. Subcutaneous crepitus was appreciated. There was a 7.5 cm × 5.5 cm area of necrotic skin located inferior-medially within the breast at the location of the initial incision and drainage site (). Her lab values demonstrated a leukocytosis of 15.6 × 10.9/L, hyponatremia of 128 mmol/L, elevated creatinine of 1.4 mg/dL, and elevated glucose of 113 mg/dL. A diagnosis of primary NF was concluded and emergency surgical intervention was arranged. Meanwhile, she was started on intravenous Meropenem, Vancomycin and Clindamycin. The patient was taken to the operating theatre shortly after presentation. Excisional debridement of the left breast with a partial mastectomy of the lower breast tissue was performed. Nipple areolar complex was removed due to evidence of necrosis. An area of 22 cm ×15 cm ×5.5 cm was removed (). The wound was packed and skin edges loosely approximated (). Her wound was re-explored 24 hours later during a dressing change. No further areas of necrosis were identified for debridement. Pathology results confirmed the diagnosis and demonstrated breast tissue with extensive acute inflammation, abscesses and necrosis with bacterial colonization of the skin and underlying subcutaneous adipose tissue (). Specimen was negative for malignancy. Intraoperative wound cultures grew coagulase negative Staphylococci, and anaerobic cultures demonstrated light growth of beta lactamase gram-negative rods. Coagulase negative Staphylococci was susceptible to oxacillin, doxycycline, gentamicin, tigecycline and vancomycin. Further speciation of anaerobic cultures was not completed. The patient was started on IV Cefazolin on postoperative day 3 and oral Metronidazole on postoperative day 7 for anaerobic coverage according to infectious disease recommendations. A plastic surgery consult was obtained for reconstruction of the left breast defect. The patient underwent local tissue rearrangement with complex closure of the left breast eight days after the index operation. Excess lateral breast tissue was rotated medially to fill the defect, a Blake drain was place, and the wound closed in multiple layers. She was discharged home nine days after admission. She was seen in office 1 month later with no issues and a well-healing incision. | No | t1_InadequateHousing |
126,459 | A 46-year-old male with a past medical history only of treated tuberculosis presented to our emergency department (ED) via ambulance after being found lying in the hallway of his apartment building. The paramedics did not find signs of trauma at the scene. The patient was fully alert and oriented and complaining of right-sided upper abdominal and chest pain. He was afebrile with a blood pressure of 92/65mm Hg, heart rate 89 beats/min, respiratory rate 24 breaths/min, and an O2 saturation of 96% on room air. On repeat measurement, blood pressure and respiratory rate improved spontaneously and remained stable throughout the remainder of his ED course. On questioning, the patient was uncertain of the duration of his pain but stated that he believed it began upon awakening earlier in the morning. He denied associated nausea, vomiting, dyspnea, fevers, chills, cough, recent illness, or similar past episodes and was able to tolerate oral food and fluids without difficulty prior to arrival. He denied taking any medications and had no known drug allergies. His social history was positive for alcohol and crack cocaine use, most recently on the night prior to arrival. The patient's living conditions were noted to be inadequate, with reports of heating issues and plumbing deficiencies in the apartment building.
Physical examination revealed a thin, middle-aged male with bi-temporal wasting who was speaking easily and did not appear to be in any distress. He had no obvious signs of recent trauma. Of note, there was no blood visible on examination of his skin, clothing, or stretcher. He had no jugular venous distension, his trachea was midline, and his cardiovascular examination was normal. However, the lung examination revealed decreased breath sounds on the right and diffuse abdominal tenderness with voluntary guarding that was increased in the mid-epigastrium and right upper quadrant. Peritoneal signs were absent, and the patient tested heme-occult negative on rectal examination.
An initial ECG obtained at triage revealed a normal sinus rhythm at 91 beats/min with a QRS axis of +75°and a QT interval (QTc) of 450ms. A large QRS voltage, prominent peaked T waves in the lateral pre-cordial leads, and prominent P waves inferiorly were also noted (). Treatment at triage was initiated with oxygen, aspirin, and nitrates. Following physician evaluation, intravenous calcium was administered despite no known history of renal insufficiency or hyperkalemia and the patient was given morphine 2mg IV with complete resolution of his pain. Following these early interventions, a repeated ECG showed no change. A portable chest x-ray was then obtained, which revealed a right-sided tension hemopneumothorax ().
Additional physical examination at that time revealed a healing 1cm linear laceration in the right posterior axillary skin fold. No crepitus, erythema, bleeding, or dried blood was present at or surrounding the site. When confronted, the patient admitted to a stab wound with an unknown object three days earlier. Thoracostomy was performed with immediate return of 1200cc of dark, non-clotted blood, and he was admitted to the hospital by the trauma service. Repeat ECG following thoracostomy revealed resolution of the peaked T waves, changes in the voltage of the P and QRS waves, a shortening of the QTc, and a shift in the QRS axis (). The patient’s initial serum potassium was 3.9 mmol/L (normal 3.5–5.0 mmol/L), and he did not develop any abnormalities in serum cardiac markers during his hospitalization. Cardiac ultrasonography was not performed. The chest tube was removed on the second day without re-accumulation of the hemopneumothorax and the patient was discharged on hospital day three. | No | t1_InadequateHousing |
67,912 | DA, a 21-year-old primigravida at 33 weeks’ gestation dated by last menstrual period was admitted to our department because of elevated temperature (39 °C), diarrhea and wasting. Unemployed, single primary school leaver. She reports that fetal movements are present, and denies leakage of fluid or vaginal bleeding. She has not done any prior prenatal visit. Problem list includes history of Positive Human Immunodeficiency virus test done in the labour room. Patient admitted with a vaginal exam (VE) showing Cervix long, posterior and closed.
Past obstetric history: negative.
Menarche at 13 years old, menstrual cycle 30 days, regular. Had never done a Pap smear nor taken contraception. She is blood group AB Rhesus positive, declares no allergies and received no antimalarial prophylaxis. Declares she has not been taking iron supplements throughout pregnancy.
Social history: Denies history of alcohol, smoking, drug abuse and has had more than four sexual partners. She reports living in a housing unit with severe physical problems, including lack of running water and inadequate heating.
Family history: Parents are married with no salaried job. Declares no history of hypertension or diabetes mellitus.
Review of system: fever, diarrhea, anorexia, weight loss and fatigue.
General appearance: wasted and oriented. Vital signs: Temperature = 39 °C, BP 95/60 mmHg, Pulse 100 bpm. HEENT: No scleral icterus, pale conjunctiva with slightly sunken eyes. Neck: normal, Lungs; normal, Heart; normal, Breasts; Symmetric, no masses. Abdomen: Gravid, non-tender. Presentation: vertex. Extremities: no lower extremity edema. Pelvis: Adequate. Sterile speculum exam (SSE): membranes intact, no vaginal discharge. Sterile vaginal exam (SVE): cervix long posterior closed. Ultrasound: vertex presentation confirmed, posterior placenta, no fetal anomalies. Fetal monitor: Baseline FHR: 155, accelerations and decelerations were present, including variability.
21-year old G1P0 at 33 weeks GA presented with elevated temperature, diarrhea and wasting.Febrile enteritis with dehydration. HIV positive.
Admit to labor and delivery room. Nothing per os. D5 NS 2500 ml/24 h. Lab: Full blood count (FBC), thick and thin films for malaria, blood electrolytes, coagulation studies, stool + culture, Widal-Felix serology, CD4 count, Viral load (VL), Aspatate aminotransferase, alanine aminotransferase, blood urea nitrogen (BUN), Antiretroviral therapy. External fetal monitor (EFM). Type and cross-match blood. Prepare for cesarean delivery.
Thick film: positive for malaria and was treated with quinine infusions. Hemoglobin: 6.4 g/dl, hematocrit: 19.3%, platelet count: 65,000, CD4: 150, VL 18,000 copies/ml. CD4 and viral load results came after the cesarean delivery.
She underwent a cesarean delivery of a live-born female who weighed 2000 g. The 5 min Apgar score was 5 and estimated blood loss was 800 ml. She was transfused 2000 ml packed cells. Hospital stay was 12 days. Mother received bromocriptine for breast milk suppression and baby received exclusive formula milk. HIV testing of the baby was negative at 18 months. | No | t1_InadequateHousing |
120,467 | A 73-year-old woman presented to her family physician with an unexplained drop in weight from 90 to 65 kg in the last 5 months, upper abdominal pain and nausea, acholic stools, and jaundice. She had a history of depression, osteoarthritis, dyslipidemia, a previous laparoscopic cholecystectomy 15 years earlier, and a mesenteric venous thrombosis. The patient reported issues with her housing, describing problems with plumbing and heating that made living conditions difficult. She declared a smoking history of 23 pack-years, consumed less than 1 alcoholic drink per week, and denied any use of illicit drugs. The patient's family history was significant: her mother had gall bladder cancer and two maternal aunts had liver and lung cancers, respectively.
Two endoscopic retrograde cholangiopancreatographies (ERCPs) were performed which revealed a common bile duct stricture – a “fuzzy” possibly mass-like area in the adjacent pancreas – and a common bile duct stent was placed to relieve the obstruction. The stomach appeared unremarkable on standard and retroflex views. Further imaging determined that the “fuzzy” appearance of the pancreas was likely due to a perforation from the first ERCP and not a mass.
Three months later, following an episode of cholangitis, she underwent a choledochojejunostomy that revealed an unresectable pancreatic mass extensively infiltrating the root of the small bowel mesentery. A biopsy of the mesentery extension of the mass confirmed a well-differentiated adenocarcinoma. Imaging confirmed her disease as T4N1M0 adenocarcinoma of the uncinate process of the pancreas. Worsening symptoms suggestive of GOO led to another ERCP; it revealed no significant evidence of duodenal obstruction up to the fourth section of the duodenum so a duodenal stent was not placed.
As a result of her advanced disease the patient was referred for consideration of palliative radiotherapy to relieve her gastrointestinal symptoms. At that time she had lost an additional 6 kg in the past month, and was admitted to hospital with an Eastern Cooperative Oncology Group (ECOG) performance status of 3. She took regular venlafaxine, risperidone, ramipril, rosuvastatin, furosemide, potassium chloride, and dalteparin, and had recently been prescribed senna glycoside, lactulose, docusate, hydromorphone, dexamethasone, and metoclopramide. She complained of aching pain across her epigastrium and upper abdominal quadrants, anorexia, and fatigue. While following a predominantly liquid-only diet, she was suffering from new bouts of projectile vomiting, nausea, and distention. In a 3-week period, her symptoms had worsened to the point where she could barely tolerate oral solids or liquids. On examination she was obese and tender over the epigastrium but devoid of distinct palpable masses. Her abdomen was somewhat tympanic but body habitus obscured more detailed findings.
She underwent a CT scan for radiation planning which surprisingly revealed profound dilatation of the stomach and proximal duodenum (Fig. , ) with extrinsic compression and likely invasion of the duodenum by the uncinate mass. She was diagnosed with malignant GOO, and several liters of fluid were urgently removed via nasogastric tube suction. In retrospect, it was thought that the obstruction had progressed from transient to complete since the time of her last endoscopy 13 days previously that had ruled out obstruction. Radiation therapy was cancelled and a gastrojejunostomy was performed to bypass the obstruction and relieve her symptoms.
A week later, her symptoms had resolved and she was able to consume solid foods. She was discharged home and began palliative gemcitabine. Unfortunately, the patient later became too weak to complete her third cycle, and 4 months following the diagnosis of GOO she passed away in a hospice. | No | t1_InadequateHousing |
107,491 | A 69-year-old unemployed woman from Asia developed symptoms of painless bilateral breast masses. Given these persistent symptoms, the patient opted for a further treatment at our hospital.
The patient reported experiencing issues with her current housing situation, including inadequate heating and plumbing, which has contributed to her overall stress and health concerns.
The patient first found bilateral breast masses without pain in June 2020. Mammography was performed on September 7, 2020 in another hospital, showing calcification foci in both breasts (BI-RADS 3). In addition, there was a focal lesion with asymmetric shadow in the middle before the upper part of the right breast (BI-RADS 4B). Breast ultrasound suggested the breast masses as possible malignant breast tumors. However, the patient refused a core needle biopsy. The patient came to our hospital for surgical treatment.
The patient had a history of type 2 diabetes for 20 years. She was given long-term treatment with 22 U Humalog 25R in the morning and 20 U Humalog 25R in the evening via subcutaneous injection as well as voglibose tablets (0.2 mg) three times a day. With a poor glucose control, no diabetic complications were found till now.
The patient had a free personal and family history.
The physical examination revealed symmetrical breasts, no orange peel appearance change, no dimpling, and double nipples without retraction or discharge. At the 1 o'clock position on the right breast, a mass (size 2 cm × 2 cm) was present with no tenderness but an unclear boundary, irregular shape, poor mobility, and skin adhesion (-). At the 12 o'clock and 1 o'clock positions on the left breast, masses (approximate sizes of 0.5 cm × 0.5 cm and 1.5 cm × 2 cm, respectively) were present with no tenderness but an unclear boundary, irregular shape, poor mobility, and skin adhesion (-). Enlarged lymph nodes were not found in the supraclavicular and subclavian regions and bilateral axilla (Figure ).
Glycosylated hemoglobin in serum was 8.3%, which exceeded the reference range of 3.6%-6.0%. Cholesterol in serum was 8.53 mmol/L, surpassing the upper limit reference 5.18 mmol/L. Triglyceride in serum was 2.89 mmol/L, also higher than the upper limit reference of 1.70 mmol/L. Other serum test results including routine blood tests, coagulation function tests, liver function tests, and tumor markers were normal.
Breast ultrasound showed the following features: (1) Solid occupation of the upper outer quadrant of both breasts (BI-RADS 4C); and (2) A solid mass at the 12 o'clock position in the left breast (BI-RADS 4B). Lymph nodes were found in the bilateral axilla and left supraclavicular region. No enlarged lymph nodes were observed in the right clavicle (Figure ). Contrast-enhanced magnetic resonance imaging (MRI) of the breast showed the following features: Irregularly enhanced images in the upper inner quadrant of the right breast (BI-RADS 4C); patchy abnormal signals in the upper outer quadrants of the left breast (BI-RADS 4B); and fibrocystic changes in both breasts (BI-RADS 2) (Figure ). | No | t1_InadequateHousing |
114,673 | The patient was 65-year-old gentleman who had history of old medullary infarction without sequelae. With social history of heavy drinking and smoking of 20 pack-year, he visited out-patient clinic due to dysphagia and chest pain. The patient reported difficulty accessing adequate food resources due to financial constraints. On esophagogastroduodenoscopy, ulcerofungating mass on esophageal mucosa at 30–33 cm below upper incisor was detected and biopsied. The pathologic report of the mass was invasive squamous cell carcinoma. Muscle layer invasion was suspicious in endoscopic ultrasound finding. There was no evidence of systemic or regional lymph node metastasis.
Robot-assisted Ivor Lewis operation was performed. Both abdominal and thoracic procedures were performed by robot-assisted technique. Gastric conduit was made intracorporeally and intra-abdominal lymph nodes were dissected to the level of celiac axis. Pyloromyotomy was performed and jejunostomy was made at proximal jejunum. In thoracic phase thoracoscopic adhesiolysis was performed due to severe pleural adhesion. After esophagectomy, mediastinal lymph node dissection up to both recurrent laryngeal lymph nodes was performed. With 25-mm-sized endoscopic end-to-end anastomosis stapler, intrathoracic esophagogastrostomy was carried out above azygos vein. Reinforcement sutures with 4-0 black silk were placed on the anastomosis site.
On the third postoperative day, high fever up to 38.4°C occurred and blood exam demonstrated leukocytosis and elevated C-reactive protein. At the following day, color of chest tube drainage changed to dark greenish and total bilirubin concentration from chest tube drain was 6.5 mg/dL. Chest computed tomography revealed loculated pleural effusion on right thoracic cavity. For drainage of effusion and identification of leakage point, thoracoscopic exploration was performed. However, gross leakage point could not be identified after draining loculated contaminated fluid. Fever was controlled and general condition of the patient was improved rapidly. However persistent leukocytosis was not normalized 2 weeks after thoracoscopic exploration. Esophagoscopy was performed 17 days after thoracoscopic exploration to detect any residual leakage point. Esophagoscopy demonstrated multiple ulcer and a leakage hole on anastomosis site (). Covered metal stent (18 mm × 60 mm; Bonastent Esophageal, EndoChoice Inc., Alpharetta, GA, USA) was placed in leakage site (). Two weeks after stent insertion, esophagoscopy was performed to check proper position of stent, 2 weeks thereafter, the stent was removed endoscopically (, ). No evidence of leakage was found in esophagogram. One week after stent removal, patient was discharged with full nutritional intake via oral route exclusively. The patient is now on regular outpatient follow-up without evidence of anastomosis site stricture for 10 months after esophagectomy. | No | t1_LackOfAdequateFood |
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