A 15-year-old boy had been experiencing a slowly worsening painful swelling in his lower back for four months, but no nerve problems. X-rays, MRI, and CT scans showed a large, expanding lesion on the left side of his sacrum and lower back bones (L4-S2), which was consistent with a condition called an ABC. This condition involves bone destruction and abnormal tissue growth. To treat it, the boy first had a procedure to block blood flow to the lesion (selective arterial embolization), then had surgery to remove the affected tissue (extended curettage). He also had spinal fusion surgery to stabilize the area (posterior fusion from L4 to S2). Pathology tests confirmed the diagnosis. Two years later, he was doing well with no pain and no signs of the lesion coming back. The only small finding on X-rays was a loose screw from the surgery, which was not causing any symptoms.


A 15-year-old male presented with a gradually progressive painful lower back swelling over a 4-month period, without associated neurological deficit. Plain lumbosacral radiography revealed an enlarged lytic lesion predominantly involving the left sacrum and lower lumbar vertebrae from L4 to S2. Magnetic resonance imaging (MRI) demonstrated a large, multi-loculated, expansile mass with a characteristic soap-bubble-like appearance extending from L4 to S2, involving the neural foramina, sacroiliac joints, and paravertebral musculature, findings consistent with an aneurysmal bone cyst (ABC). Lumbosacral computed tomography (CT) further delineated the lytic lesion, showing involvement of the sacral alae, partial destruction of the S1 and S2 vertebral bodies, and complete destruction of the left L5 pedicle. Arterial angiography confirmed the vascularity of the lesion, supporting the diagnosis of an ABC. Preoperative selective arterial embolization was performed on the day of surgery to reduce vascular supply and minimize intraoperative bleeding. The patient then underwent extended surgical excision via curettage, followed by posterior pedicle screw and rod lumbopelvic reconstruction (L4-S2). Histopathological examination of the resected tissue confirmed the diagnosis of an aneurysmal bone cyst, demonstrating osteoid foci, spindle cells, multinucleated giant cells, and reactive osteoblastic changes. Two years postoperatively, the patient remained neurologically intact and asymptomatic, with no radiographic evidence of lesion recurrence. The only radiographic finding on follow-up was asymptomatic loosening of the inferior left-sided set screw, indicating mechanical wear rather than biological recurrence or progression of disease.


A 20-year-old woman who was healthy had a fever for two days and went to the doctor. She had sex for the first time six months before. Tests showed she got infected with a virus called CMV first. About five months later, she had a fever again and swollen lymph nodes in her neck. Tests at that time showed she had a new virus infection called EBV. This means she got infected with EBV after already having CMV. Both infections were new ones at that time, and she recovered fully without serious problems.


A 20-year-old healthy Japanese woman first had a two-day fever and visited the clinic. She had sex for the first time six months earlier. Tests showed she was infected with cytomegalovirus (CMV) for the first time. About five months later, she had a fever and swollen lymph nodes in her neck. Tests at that time showed she was infected with Epstein-Barr virus (EBV) for the first time. This means she got CMV first, then EBV a few months later. Both infections were confirmed by blood tests that detect specific antibodies. Her symptoms improved with treatment, and follow-up tests showed the CMV infection had fully cleared after three months. The sequence of infections was clear and matched the timeline of her symptoms.


{
    "proficient_health_literacy": "A 20-year-old healthy Japanese female presented with a 2-day history of high fever to the emergency department at Kawasaki Medical School. Her medical history included prior episodes of mycoplasma pneumonia at ages 1 and 18. She reported her first sexual encounter six months prior. On examination, she exhibited pharyngeal erythema and lymphadenopathy in the posterior cervical and left axillary regions, with no significant findings on neurological or physical assessment. Vital signs at admission included a heart rate of 108 beats/minute, blood pressure of 101/58 mmHg, and a temperature of 38.9°C. Laboratory findings revealed leukocytopenia (white blood cell count: 1710/μL; neutrophils 76.0%, monocytes 5.0%, lymphocytes 18.0%, atypical lymphocytes 1.0%) and elevated C-reactive protein (CRP: 3.92 mg/dL). Mild hepatic dysfunction was noted: γ-glutamyl transferase (γ-GTP) 78 U/L, alkaline phosphatase (ALP) 276 U/L, aspartate aminotransferase (AST) 30 U/L, alanine aminotransferase (ALT) 28 U/L. Chest X-ray and computed tomography (CT) showed no evidence of pneumonia; abdominal CT revealed slight hepatomegaly and splenomegaly. Serological testing for influenza A/B antigens and Mycoplasma pneumonia antigen was negative. Hepatitis B surface antigen and hepatitis C antibody were negative. Human immunodeficiency virus (HIV) antigen/antibody test was negative (cutoff index <0.3). Treponema pallidum hemagglutination (TPHA) was negative. Urine culture yielded small amounts of Corynebacterium sp. and Gram-positive cocci, consistent with bacteriuria, though no pathogenic bacteria were isolated. Given the elevated CRP, levofloxacin (500 mg/day) was initiated empirically for suspected bacterial infection. The patient had a history of suspected bladder infection by her primary care provider. Viral serology demonstrated: CMV IgM antibody 3.89 (+) (enzyme immunoassay, EIA), CMV IgG antibody


A 37-year-old woman had a swollen belly, swollen feet, and yellow eyes because of a blockage in her liver blood vessels. Doctors found the problem was Budd Chiari syndrome, where the veins carrying blood from the liver were blocked. She had a surgery called a side-to-side portacaval shunt to fix the blockage, using a vein from her leg as a bridge. After the surgery, the shunt got blocked early, so doctors placed a small metal tube (stent) inside it to open it up again. This worked, and she has been feeling better for five years with no symptoms and is on blood-thinning medicine to prevent clots.


A 37-year-old woman had a condition called Budd Chiari syndrome, which caused her liver to swell and fluid to build up in her abdomen. She had yellowing of the eyes, swelling in her legs, and a firm, enlarged liver. Tests showed that the veins carrying blood from her liver were blocked, especially the hepatic veins. Imaging confirmed a narrowed inferior vena cava and complete blockage of the hepatic veins. She underwent a side-to-side portacaval shunt using a vein from her leg as a graft to reroute blood flow. However, the shunt became blocked early, and this was fixed by placing a metallic stent across the shunt. After treatment, her symptoms improved, and she has been symptom-free for five years with regular follow-up and blood thinners.


{
    "proficient_health_literacy": "A 37-year-old female presented with a two-week history of progressive abdominal distension, pedal edema, and jaundice. Physical examination revealed icterus, an enlarged and firm liver, and gross ascites. Laboratory findings demonstrated conjugated hyperbilirubinemia, mild derangement of transaminases, and elevated alkaline phosphatase. Imaging via ultrasonography with color Doppler identified an enlarged liver with hypertrophied caudate lobe, a 1.1 cm portal vein with hepatopetal flow, complete occlusion of the right hepatic vein, patent but narrowed inferior vena cava (IVC) compressed by the caudate lobe, and free abdominal fluid. Splenic and superior mesenteric veins were intact. Liver biopsy confirmed the diagnosis of Budd Chiari syndrome. Prothrombotic workup was negative for underlying thrombophilic disorders. Transjugular venography revealed 90% stenosis of the IVC with a 14 mmHg pressure gradient across the narrowing and non-cannulation of the hepatic veins beyond their origins, indicating complete occlusion at the hepatic vein ostia. An 18 × 63 mm metallic stent was deployed across the IVC segment, followed by balloon dilatation using a 16 mm balloon. Percutaneous transhepatic venography under ultrasound guidance demonstrated that the left hepatic vein was patent only in its proximal segment, with distal occlusion (2–3 cm) and collateral drainage; the right hepatic vein was completely occluded, and the middle hepatic vein exhibited long-segment total occlusion (>3 cm). Attempted recanalization of the left hepatic vein failed due to extensive fibrosis and long segmental occlusion. The patient subsequently underwent a side-to-side portocaval shunt using the right external iliac vein as the H-graft. Postoperative course was uneventful, with initiation of anticoagulation. Six weeks postoperatively, she was re-admitted with recurrent pedal edema and ascites. Doppler ultrasound revealed patchy flow through the shunt. Transjugular venography confirmed patency of the IVC stent but demonstrated narrowing of the portosystemic graft with a gradient exceeding 15 mmHg at the IVC end. Given the acute angulation of the shunt relative to the IVC, a


A 70-year-old man had belly pain for 2 days, his stomach was swollen, he was feeling sick and threw up, and hadn’t had a bowel movement in 2 days. A scan showed his last part of small intestine was swollen and had a sharp object stuck in it — like a fish bone — that had pierced through the wall. The doctors took out the fish bone and cleaned the area. The man got better and was home in 6 days. He said he accidentally swallowed the fish bone 5 days before.


A 70-year-old man came to the emergency room with abdominal pain that had been worsening for 48 hours, along with swelling in his abdomen, nausea, vomiting, and not having a bowel movement for two days. An abdominal CT scan showed that the end of the small intestine (terminal ileum) was swollen, measuring 30mm, and there was a sharp foreign object located 15 centimeters from the end of this section. The object had pierced through the wall of the intestine. During surgery, the fish bone was removed, and the damaged area was cleaned and closed. The patient recovered well and was discharged after six days. He later admitted that he had accidentally swallowed the fish bone five days earlier. His overall condition improved during recovery and there were no serious complications.


{
    "proficient_health_literacy": "A 70-year-old male with no significant comorbidities was referred to the emergency department by his family physician with a 48-hour history of progressive abdominal pain, marked abdominal distension, nausea, vomiting, and a last bowel movement reported two days prior. On physical examination, vital signs were: temperature 37.3 °C, pulse 110 beats per minute, respiratory rate 24 breaths per minute, and blood pressure 110/60 mmHg. Abdominal examination revealed right iliac fossa tenderness, generalized abdominal distension, and an empty rectal ampulla on digital rectal examination. Laboratory findings included hyperleukocytosis (white blood cell count: 15,700/mm³), hemoglobin 11 g/dL, platelet count 159,000/mm³, and elevated C-reactive protein (180 mg/L); hepatic and renal function tests were within normal limits. Abdominal X-ray demonstrated hydro-aeric levels in the ileal segments, consistent with ileal obstruction, without evidence of pneumoperitoneum. Abdomino-pelvic CT imaging revealed a 30 mm distension of the terminal ileum, upstream of a transitional zone where a rectangular, planar foreign body was identified. Based on these findings, the patient was diagnosed with ileal perforation secondary to foreign body penetration. Prior to surgery, the patient underwent optimization of his hemodynamic status with nasogastric tube suction and intravenous fluid resuscitation. An emergency laparotomy was performed under general anesthesia with endotracheal intubation, conducted by a fifth-year and fourth-year surgical resident. Preoperative prophylactic antibiotics were administered. Intraoperatively, a sharp foreign body measuring 3 cm × 2 cm was identified at the 15 proximal centimeters of the terminal ileum, penetrating through the ileal wall. The foreign body was successfully removed and identified as a fish bone. The margins of the perforation were excised, and primary anastomosis was performed. Postoperative recovery was uneventful; the patient was discharged on postoperative day 6. Patient history confirmed incidental ingestion of the fish bone five days prior to presentation. The postoperative course was uncomplicated, with resolution of systemic inflammation and restoration of gastrointestinal continuity. The pathophysiological mechanism involved mechanical obstruction and subsequent perforation


A 74-year-old man had blurry vision in both eyes because of cataracts. His eye doctor planned to fix his right eye with cataract surgery. During the surgery, heat damaged the front and outer layer of his right eye. The damage was serious — his eye could only see with his hand moving, and the pressure inside the eye was very low. The front part of the eye became cloudy, and fluid leaked out. The surgery team could not sew the damaged part back together because it was too loose and broken. So, they took a piece of healthy tissue from a donor and put it into the damaged area to fix the eye. After that, they removed the cloudy lens part and placed a clear lens inside the eye. It took 7 months for the new lens to settle in place. Now, his vision is better — it’s 2/20 in his right eye, and the eye is stable with less cloudiness.


A 74-year-old man had severe eye damage during cataract surgery in his right eye. He had prostate enlargement but no history of dementia. Before surgery, he had blurry vision due to cataracts, with good vision and normal eye pressure. During the procedure, heat from the surgery caused serious injury to both the cornea and sclera (the white part of the eye). The injury led to heavy clouding of the cornea and fluid leaking into the eye. The wound was initially closed with stitches, but fluid kept leaking, so more material was injected. The next day, he was transferred to our hospital, where his vision had dropped to hand motion and eye pressure was only 3 mm Hg. The sclera was badly damaged and could not be repaired directly because it was too loose. Instead, a donor scleral graft was transplanted to cover the damaged area using 10-0 nylon sutures. After the graft healed and fluid stopped leaking, the lens nucleus was removed from the wound. Pathology showed the damaged tissue had coagulation necrosis with no inflammation. Three months later, inflammation caused macular edema, which was treated with anterior vitrectomy. Finally, an intraocular lens was placed in the ciliary sulcus seven months after surgery. His vision improved to 2/20 in the right eye, and his eye pressure stabilized with less corneal clouding.


{
    "proficient_health_literacy": "A 74-year-old male presented in October 2015 with blurred vision in both eyes due to senile cataract, with baseline visual acuity of 6/20 in the right eye (OD) and 8/20 in the left eye (OS), and normal intraocular pressure (IOP). Slit-lamp examination revealed mild cortical cataract in both eyes, with no notable fundus abnormalities. The initial ophthalmologic management plan included phacoemulsification for the right eye. The patient had a history of benign prostatic hyperplasia (BPH) but no history of dementia. Prior to phacoemulsification, viscoelastic agents with high cohesive properties were injected into the anterior chamber to induce pupillary dilation following miosis induced by hydrodissection in the right eye. Shortly after initiating phacoemulsification, a severe thermal corneoscleral injury occurred, characterized by extensive thermal damage to the corneal stroma and sclera. The wound was initially managed with tight suturing using pedunculated conjunctiva; however, persistent intraocular fluid leakage necessitated repeated injection of viscoelastic material. The next day, the patient was transferred to our institution, where he presented with hand motion vision and an IOP of 3 mm Hg OD. Histological evaluation of the injured sclera revealed coagulation necrosis with eosinophilic material accumulation, consistent with thermal injury and lack of inflammatory cell infiltration, indicating a direct thermal insult without significant immune response. The scleral wound was found to be actively opening upon conjunctival incision, and due to marked scleral mobility, direct suture closure was not feasible. As a result, a donor scleral graft was transplanted to the injured site using 10-0 nylon sutures. Post-transplantation, intraocular fluid leakage was confirmed to be absent, allowing safe extraction of the lens nucleus from the newly formed temporal wound. Histopathological analysis confirmed favorable graft attachment and restoration of IOP to normal levels. Three months postoperatively, macular edema developed secondary to intraocular inflammation driven by residual lens cortex, leading to anterior vitrectomy, which resolved the edema. An intraocular lens (IOL) was ultimately implanted in the ciliary sulcus seven months after surgery. At the final follow-up in October 2016, the patient achieved a visual acuity of 2


A baby boy, just 4 days old, had a small, yellowish-white spot found on the inside of his left eye's back part. The spot was about the size of 1.5 eye circles. When doctors looked at it with a special eye test, it showed bright spots and a little leaking. Seven months later, the spot was gone and the eye looked normal. The blood vessels in the eye were a bit twisted but didn't leak anymore. No treatment was needed because the spot just disappeared on its own.


A 4-day-old male infant was found to have a small, harmless growth called an isolated retinal astrocytic hamartoma in the nasal retina of his left eye. At first, it appeared as a yellowish-white flat spot about 1.5 times the size of a normal retina disc. Fluorescein angiography showed the area was abnormally bright with a little leakage, which is a common finding in such growths. Seven months later, the spot had completely disappeared during a fundus exam, and the eye’s blood vessels looked slightly twisted but without any leakage. The right eye was normal throughout. This suggests that the growth may have gone away on its own without treatment, a process known as spontaneous regression.


A 4-day-old male infant, delivered at 40 weeks' gestation with a birth weight of 3660 g, was admitted to the Department of Neonatology at The Second Hospital of Jilin University in February 2022 due to dyspnea. Delivery was via episiotomy combined with forceps. No cutaneous abnormalities were noted. Brain magnetic resonance imaging (MRI) revealed bilateral short T1 signal abnormalities beneath the occipital cranial plate, consistent with subarachnoid hemorrhage, though no associated neurological deficits or family history of congenital or genetic disorders were present. Routine retinal screening using RetCam 3 (Clarity Medical Systems, Inc.) demonstrated a normal right retina. In contrast, a color fundus photograph of the left eye identified a solitary, yellowish-white, flat retinal lesion measuring approximately 1.5 disc diameters in the nasal retina. Fluorescein angiography (FA) demonstrated diffuse hyperfluorescence with mild fluorescence leakage, suggesting abnormal vascular permeability and perfusion within the lesion. B-scan ultrasound was unremarkable, showing no distinct calcifications or structural abnormalities, and the mass was inapparent on imaging. No therapeutic intervention was initiated, and the patient was followed clinically. At three months post-initial presentation, a reduction in lesion size was observed, with FA revealing decreased vascularization and mild mottled hyperfluorescence, indicating partial vascular normalization and possible resolution of the vascular dysregulation. Seven months after initial detection, fundus examination confirmed complete absence of the retinal lesion in the left eye. Repeat fluorescein angiography showed mild tortuosity of the surrounding retinal vessels without evidence of leakage, consistent with restored vascular integrity. The right retina remained unaffected. These findings support the clinical observation that isolated retinal astrocytic hamartoma (RAH) may exhibit spontaneous regression, likely due to the self-limiting nature of the lesion's vascular and cellular architecture, with a probable mechanism involving gradual resolution of the astrocytic proliferation and vascular remodeling over time. The absence of systemic involvement, familial predisposition, or associated anomalies further suggests a sporadic, non-malignant, and benign developmental origin of the lesion.


A 78-year-old man with liver damage from years of drinking alcohol had a cancer in his liver that broke into pieces and started bleeding. The bleeding was so bad it filled his belly with blood, and he needed surgery right away. Doctors opened his belly and saw a lot of blood and two spots where the liver had torn. The bleeding wouldn’t stop with normal methods. So they used a special machine that sends heat to the blood vessels feeding the cancer, and it worked — the bleeding stopped. The surgery took 90 minutes and he needed blood and medicine to stay alive. After the surgery, he went to the hospital room to recover. Two days later, he was moved to a regular room and didn’t need more medicine. His liver was still strong enough to heal, even though it was damaged. Later, he got a serious problem called hepatorenal syndrome, but didn’t need dialysis. He stayed in the hospital and was followed by a team that helps people with serious illness. Sadly, he passed away two months later because the cancer kept getting worse.


A 78-year-old man with long-term alcohol-related liver damage (cirrhosis) and several liver tumors (multifocal hepatocellular carcinoma) was admitted to the hospital after his abdomen suddenly filled with blood due to ruptured tumors. An abdominal CT scan showed multiple bleeding spots in both sides of his liver. He was in serious condition and urgently taken to the operating room, where a large amount of blood (4 liters) was found in his abdominal cavity (hemoperitoneum). During surgery, it was found that his liver was heavily damaged and covered by tumors, with two areas (segments II and IV) bleeding uncontrollably. Standard methods to stop the bleeding failed. To control the bleeding, doctors used a procedure called radiofrequency ablation (RFA), which applies heat to the blood vessels feeding the tumors, sealing them off. This was done around both tumors for a total of 40 minutes, and the bleeding stopped successfully. The surgery took 90 minutes, and he needed blood transfusions and medication to support his blood pressure. After surgery, he was moved to the intensive care unit and stayed there for two days before being transferred to a regular medical floor. His liver enzymes were very high after surgery, but he did not develop liver failure. He later developed a complication called hepatorenal syndrome on day 9, which affected his kidneys, but he did not need dialysis. His overall condition remained stable, and he was followed up by a palliative care team. Unfortunately, he passed away two months later due to worsening liver disease.


{
    "proficient_health_literacy": "We present a case report of a 78-year-old white male with alcoholic cirrhosis and multifocal hepatocellular carcinoma (HCC), complicated by ascites and portosystemic encephalopathy. The patient's history includes a prior wedge resection of segment II for HCC (G2) two years prior, followed by annual surveillance including computed tomography (CT) imaging. Due to advanced age and poor liver function, he was not considered a candidate for liver transplantation (LT). He presented to the emergency department with decompensated ascites, abdominal tension, and lower limb edema. During hospitalization, his hematocrit dropped abruptly (hemoglobin from 9.3 g/L to 6.7 g/L over a 3-hour period), indicating significant hemorrhage. Abdominal CT revealed multiple bilateral foci of HCC with active acute bleeding from one lesion. His Model for End-Stage Liver Disease (MELD) score was 19, Child–Pugh score C11, total bilirubin 8 mg/dL, and alpha-fetoprotein (AFP) level of 604 μg/L—indicative of aggressive HCC. The patient was hemodynamically unstable and required urgent surgical intervention for hemorrhagic shock. A midline laparotomy was performed, revealing a massive hemoperitoneum (4 L) with a cirrhotic liver exhibiting recanalization of the umbilical vein and development of collateral circulation. The liver was completely subverted by tumor mass, with two spontaneous, uncontrollable lacerations identified in segments II and IV. Conventional hemostatic measures—including argon beam coagulation, oxidized regenerated cellulose, and fibrin glue—failed to achieve hemostasis. Given the multifocal nature of the HCC, poor hepatic reserve, and the presence of active bleeding from multiple vascular afferents, a strategy of radiofrequency ablation (RFA) was employed to coagulate the feeding vessels of each tumor nodule. Circumferential RFA cycles were applied to both nodules, totaling 40 minutes of ablation duration. This approach successfully achieved hemostasis and controlled the bleeding from the ruptured hepatocellular carcinoma. The surgical procedure lasted 90 minutes, during which the patient required three units of packed red blood cells (PRBCs) and vasopressor support with noradrenal


A 36-year-old woman had a hard, rubbery lump in her right upper belly that had been there for two months. She didn’t have any other health problems. Doctors found the lump was big — about 13 to 14 centimeters — and it had a small, bright part inside. A scan showed the lump was in her liver and also spread a little to her lower belly. She had surgery to remove part of her liver and a piece of tissue called the omentum. After the surgery, doctors looked at the tissue and found it was a rare kind of cancer called low-grade malignant epithelioid mesothelioma. This type of cancer grows slowly and doesn’t spread easily. Six months after surgery, she has not had any signs of cancer coming back. This is a good sign. It’s very rare for this kind of cancer to start in the liver, and even rarer for it to be in both the liver and the omentum at the same time.


A 36-year-old woman was admitted to the hospital after discovering a hard, elastic lump in her right upper abdomen that had been causing pain for two months. Imaging tests showed a large cystic mass in her right liver, about 13 to 14 centimeters in size, with a small blood-filled spot inside. A PET scan also showed abnormal activity in the liver and lower abdomen, suggesting a tumor. The patient had no history of asbestos exposure or other known risk factors. She underwent surgery to remove part of her liver and a portion of the omentum (a fatty tissue layer in the abdomen). Pathology results showed that the tumors were low-grade malignant epithelioid mesothelioma — a rare type of cancer that usually starts in the lining of organs. This type of cancer is very uncommon in the liver, and this case is one of the youngest reported in women. The tumors in both the liver and omentum had similar features, including a fibrous capsule and low growth rate, which suggests they are separate, primary tumors rather than spread from one area. After six months of follow-up, the patient has shown no signs of cancer returning. While rare, mesothelioma can sometimes occur in the liver or omentum, and in this case, both tumors were considered low-grade, meaning they are less aggressive and have a better prognosis.


{
    "proficient_health_literacy": "A 36-year-old woman presented with a 2-month history of abdominal and back pain, leading to referral and admission for evaluation of a hard, elastic, poorly flexible mass in the right upper abdomen. No signs of obstructive jaundice or abdominal tenderness were present. Laboratory findings revealed anemia (hemoglobin = 10.6 g/dL), thrombocytosis (43.9 × 10⁴/μL), and elevated C-reactive protein (2.71 mg/dL); all other laboratory parameters, including tumor markers α-fetoprotein (AFP), carcinoembryonic antigen (CEA), and cancer antigen (CA)19-9, were within normal limits. Abdominal ultrasonography identified a large, heterogeneous space-occupying lesion in the right lobe of the liver, measuring 15 cm in diameter, with evidence of hemorrhage and a hypervascular mural nodule. Contrast-enhanced computed tomography (CT) demonstrated a cystic mass measuring 13 × 14 × 11 cm in the right liver lobe with an enhanced mural nodule. Magnetic resonance imaging (MRI) showed hyperintense T2-weighted components consistent with hemorrhagic content. 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) revealed abnormal metabolic accumulation in the liver and lower abdominal region, prompting surgical intervention. The procedure included hepatectomy of the posterior segment and partial resection of the omentum, which was identified as a lesion on FDG-PET. Gross examination revealed a massive cystic tumor measuring 18 × 15 cm containing hemorrhagic fluid, with multinodular, mucinous, brownish or yellowish lesions observed in the extra-cystic wall. The omental lesions were two nodular tumors measuring 2.1 × 1.3 cm and 0.3 × 0.3 cm, both slightly brownish in appearance. Microscopic evaluation demonstrated tubular, cystic, and spindle arrangements of epithelioid cells with clear or eosinophilic cytoplasm in both hepatic and omental tumors. Immunohistochemical analysis showed positive staining for AE1/AE3, EMA, CK19, CK7, CD10, and calretinin; partial or weak positivity for CK5/6, D2-40


An 82-year-old man had pain in his belly for nine days, along with vomiting and belly swelling. He had a history of gallstones before. Tests showed his gallbladder was small and his intestines were stretched out, with a gallstone stuck in the small intestine, blocking the flow. This caused air to show up in the bile duct, which means a gallstone got into the intestine through a hole between the gallbladder and the small intestine. The doctors did an emergency surgery to remove the stone from the intestine. They left the hole alone because cutting it could have hurt the small intestine. After surgery, he recovered well and went home without problems. He stayed healthy for 16 months after that.


An 82-year-old man with a history of gallstones presented with abdominal pain, distension, and vomiting that had lasted for nine days. His abdomen was swollen, and the bowel sounds were loud. Ultrasound showed a shrunken gallbladder and swollen intestines. A CT scan found a gallstone stuck in the small intestine, blocking it, along with air in the bile ducts — a sign of gallstone ileus and a connection between the gallbladder and the duodenum (cholecystoduodenal fistula). The patient underwent emergency surgery, where the gallstone was removed from the intestine (enterolithotomy). The connection between the gallbladder and duodenum was not repaired because it could have caused serious injury to the duodenum. After surgery, he recovered well and was discharged on day six. He has remained symptom-free for 16 months.


{
    "proficient_health_literacy": "An 82-year-old frail male with a history of hypertension for 15 years and previously diagnosed cholelithiasis (eight years prior) presented with a nine-day history of abdominal distension, constipation, localized periumbilical pain described as intermittent, nonradiating, and multiple episodes of nonprojectile, nonbilious vomiting containing food particles. He denied fever, jaundice, hematochezia, melena, urinary changes, or recent abdominal trauma. His recent diagnosis of bronchiectasis was managed with low-flow oxygen therapy. Physical examination revealed normal vital signs, a distended abdomen without tenderness, and hyperactive bowel sounds. Laboratory investigations, including complete blood count and biochemistry, were within normal limits. Abdominal ultrasound demonstrated a contracted gallbladder with distended bowel loops, consistent with intestinal obstruction. Abdominal computed tomography (CT) of the abdomen and pelvis revealed dilated loops of the small intestine with hyperdense intramural calculi and air within the biliary tree, confirming the diagnosis of gallstone ileus with associated cholecystoduodenal fistula. Initial management included intravenous fluid resuscitation, nasogastric tube insertion, analgesia, and nil-by-mouth status. A Foley catheter was placed, and urinary output was monitored closely. The patient underwent an emergency exploratory laparotomy via a lower midline incision under spinal anesthesia, performed within 24 hours due to concerns for chest morbidity. Intraoperatively, a single 4.5 × 2 cm gallstone was identified impacted in the terminal ileum, located 10 cm proximal to the ileocaecal junction. The ileal segment at the site of impaction was intact and healthy, with proximal bowel dilation. An incidental finding was a Meckel's diverticulum measuring 60 cm proximal to the ileocaecal junction, characterized by a wide base. A longitudinal enterotomy was performed proximal to the stone impaction to facilitate stone extraction via milking, followed by transverse repair of the enterotomy. The gallstone responsible for the intestinal obstruction was successfully removed. The cholecystoduodenal fistula was not ligated or repaired, as the procedure would have carried a high risk of duodenal injury, particularly given the anatomical proximity and the potential for bile-induced duodenal perforation or stricture. Postoperative course was un


A 65-year-old man with high blood pressure, diabetes, obesity, and liver disease had been on dialysis for two years. He often missed his dialysis sessions and didn’t follow his diet, which made his body weak. During one session, he felt tired, dizzy, and confused. His blood pressure was very low (50/30), and his heart was not working well. Tests showed his heart was wrapped in a thick, stiff layer (pericardium) that was squeezing it, making it hard to pump blood. This condition, called constrictive pericarditis, was caused by long-term dialysis. The doctors removed the thick layer (pericardiectomy) and found it was full of scar tissue and calcium, not infection. After the surgery, he started dialysis more regularly and followed his diet. He’s now feeling better and going to dialysis every week as planned.


A 65-year-old man with long-standing conditions like high blood pressure, diabetes, obesity, and liver disease on hemodialysis for two years began feeling unwell during one of his dialysis sessions. He reported feeling tired, lightheaded, and confused, but no chest pain or shortness of breath. He had a history of missing dialysis sessions and not following his diet, which likely worsened his condition.

At the time of admission, he was very weak, had a dangerously low blood pressure (50/30 mmHg), and showed signs of shock. His heart exam revealed weak sounds and a slow refill time, and his ECG showed low electrical activity in the heart. An echocardiogram found a thickened pericardium (the sac around the heart) with no fluid buildup, and cardiac catheterization confirmed that the pressures in all heart chambers were equal—this is a key sign of constrictive pericarditis.

Tests ruled out infection, heart disease, and other causes. Pathology of the removed pericardium showed heavy scarring and calcium deposits, with no signs of infection or inflammation. These findings point to dialysis-related constrictive pericarditis (DICP), a condition that can develop in people on long-term hemodialysis due to poor dialysis adherence and high fluid retention.

The patient underwent surgery to remove the thickened pericardium (pericardiectomy), which improved his symptoms. After recovery, he started attending dialysis more regularly, followed his diet, and now manages his condition better. This case highlights the importance of consistent dialysis attendance and dietary control in preventing serious complications like constrictive pericarditis.


{
    "proficient_health_literacy": "A 65-year-old male with a history of hypertension, type 2 diabetes mellitus, morbid obesity, and cirrhosis secondary to non-alcoholic steatohepatitis (NASH) presented with symptoms of malaise, lightheadedness, and confusion during a hemodialysis session. He had been on hemodialysis for two years due to diabetic nephropathy, but exhibited chronic non-adherence to treatment, with only three to four sessions per week attended, resulting in an actual Kt/V of 1.5–2.0, significantly below the calculated standard Kt/V of 2.45 under ideal adherence. His dialysis prescription included a high-flux polysulfone membrane with a surface area of 2.2 m², a blood flow rate (Qb) of 370 mL/min, and a dialysate flow rate (Qd) of 800 mL/min. Dialysate composition consisted of calcium 2.5 mEq/L, potassium 1 mEq/L, sodium 138 mEq/L, bicarbonate 36 mmol/L, and unfractionated heparin 5000 IU/session. He was also prescribed allopurinol 100 mg/day, sertraline 50 mg/day, esomeprazole 40 mg/day, and sevelamer 2.4 g three times daily.\n\nAt presentation, the patient was anuric and in hypotensive shock with a blood pressure of 50/30 mmHg, prolonged capillary refill time, and jugular venous stasis. Physical examination revealed pallor, cyanosis, and hypophonic heart murmurs; respiratory rate was 16 breaths per minute, oxygen saturation 88% in room air, and no signs of pulmonary pathology. Cardiac auscultation showed no parasternal or apex murmurs, with a heart rate of 88 bpm. Neurological examination demonstrated altered mental status and bradykinesia. Electrocardiography revealed sinus rhythm, low diffuse QRS voltage, and evidence of altered ventricular repolarization, consistent with impaired conduction and reduced myocardial voltage.\n\nLaboratory findings included: hemoglobin 9.8 g/dL, hematocrit 29.5%, leukocytes 5,230/mm³,


A 4-year-old girl was born with her index finger and thumb bigger than the other fingers. These fingers have gotten larger over time and now cause pain, tingling, and sometimes a bluish color, especially at night. The fingers are stiff, especially on the right hand, but she can still grip things she needs to hold. The big fingers are not normal — they have extra fat and fibrous tissue, like soft, firm stuff that grows around the nerves. This is called macrodactyly. Her siblings are healthy, and she had a normal birth. The doctors saw this on X-rays, which showed thick soft tissue and bigger bones in those fingers. Before surgery, everything looked the same. They planned surgery to fix the second finger, which was the worst, because it hurt the most and made her hand stiff. They removed the extra soft tissue (fat and fibrous stuff) without touching the bone or nerve. Then they cut a small piece of bone to straighten the finger and used a tiny metal wire to hold it in place while it healed. After surgery, she had regular check-ups and physical therapy to move her fingers better and reduce stiffness. She is getting better — her grip is stronger, her fingers move more, and the pain and stiffness are going down. She will keep being checked to make sure everything is healing well.


A 4-year-old girl has had enlarged index and thumb fingers since birth. Over time, these fingers have gotten larger, causing pain, tingling, and occasional bluish coloring—especially at night. The enlargement is most noticeable in the right hand, where the index and second fingers are much bigger than the others. The fingers feel firm and are slightly stiff, especially when gripping things. She can still hold objects, but her right hand has noticeable stiffness.

The condition is called macrodactyly, a type of FLH (fibrolipomatous hamartoma), which means abnormal growth of soft tissues like fat and fibrous tissue around the nerves in the hand. The swelling is not in the bones, but in the soft tissue, and it’s most prominent near the median nerve. X-rays showed increased soft tissue and bone growth in the affected fingers, which matches what’s seen in this condition.

Before surgery, doctors confirmed the diagnosis using X-rays. Since MRI was not available due to long wait times, they relied on X-rays to plan treatment. The surgery focused on the second finger, which was the most enlarged and caused the most problems. The procedure included removing the excess soft tissue (fibroadipose tissue), correcting the bent angle of the finger with a bone cut (wedge osteotomy), and using a small metal wire (K-Wire) to help the bone heal in the right position.

The surgery was done to reduce pain, improve finger movement, and make daily activities easier. After surgery, the child had regular follow-ups and physical therapy to improve hand strength and flexibility. Over time, she showed better grip, less stiffness, and improved hand function. She continues to be monitored for long-term results.


{
    "proficient_health_literacy": "A 4-year-old female patient presents with congenital macrodactyly of the right index finger and thumb, a hallmark feature of fibrolipomatous hamartoma (FLH). The enlargement is disproportionate, with the index and thumb significantly larger than adjacent digits, and is characterized by firm, swollen tissue upon palpation consistent with fibroadipose proliferation. Radiographic evaluation reveals increased soft tissue density and bony enlargement of the first and second phalanges of the right hand, particularly on the palmar surface, confirming the radiological pattern typical of FLH involving both soft tissue and bone. The condition has been progressive since birth, with symptoms including nocturnal pain, paresthesia (tingling), and episodic cyanosis of the affected digits, suggesting compromised microvascular perfusion and/or nerve compression. These symptoms correlate anatomically with the course of the median nerve through the wrist and hand, a region commonly involved in FLH due to the infiltrative nature of the fibroadipose lesion.\n\nDetailed measurements show the right first finger measures 6 × 2.0 cm and the second finger 6 × 1.9 cm, with a 20-degree angulation directed toward the ulnar side at the distal and middle phalanges. Sensory function is preserved throughout the affected digits—base, middle, and tip—comparable to contralateral and non-affected sides, with no evidence of sensory loss or tenderness. The mother’s first finger measures 4 × 1.5 cm and second finger 5 × 1.5 cm, indicating a relative degree of familial variation, though not a direct hereditary pattern.\n\nPreoperative imaging, including initial X-rays, demonstrated widespread soft tissue edema and hyperdensity consistent with fibroadipose tissue expansion. Although MRI was planned as the gold standard for detailed soft tissue characterization and to confirm the diagnosis of fibrolipomatous hamartoma, its unavailability due to prolonged waiting lists necessitated reliance on X-ray findings for diagnostic and surgical planning. The absence of significant bony involvement in the excised tissue confirms that FLH is primarily a soft tissue hamartoma, with fibrous tissue derived from proliferative fibroblasts and collagen deposition around the nerve sheath, and adipose tissue representing abnormal fat accumulation within and adjacent to the nerve bundles. The excised mass exhibited a soft, pliable consistency with intermixed fibrous nodules,


A 60-year-old woman who wears dentures had a sore spot on the inside of her lower right cheek for a month. She also had dry mouth. The doctor saw redness at the corners of her mouth and a small, painless lump near her tooth area, likely caused by a bad-fitting denture. A test found a rare type of yeast called C. calyptogenae, which is not common and usually lives in seawater or clams. This yeast matched almost perfectly with a known strain. After two weeks of using a mouth spray and a cream with miconazole and fusidic acid, the redness went down. The yeast was no longer found in her mouth after checking again. The doctor fixed her denture to prevent it from happening again. Her symptoms got better, and she’s now doing well.


A 60-year-old woman who wore dentures was diagnosed with angular cheilitis, a condition causing irritation and redness at the corners of her mouth. She also had a small, painless lump on the inside of her lower right cheek, likely caused by a poorly fitting denture. Testing of her mouth samples showed a rare yeast called C. calyptogenae, which is not commonly found in the mouth. The yeast was identified through laboratory tests that compared its genetic code to known strains, showing 99.6% similarity in one part of its DNA and 100% in another. After two weeks of treatment with a mouthwash and a topical cream containing miconazole and fusidic acid, her symptoms improved, with less redness. Follow-up testing showed no trace of the yeast. The doctor also recommended a new denture to better fit her mouth and prevent the problem from coming back.


{
    "proficient_health_literacy": "A 60-year-old denture-wearing Malaysian woman was referred to the Oral Medicine Clinic, Universiti Malaya, in February 2020, presenting with a painless swelling on the lower right cheek that had persisted for one month. She reported moderate xerostomia, quantified by a Clinical Oral Dryness Score of five. On clinical examination, she was partially edentulous, with no facial swelling or palpable lymphadenopathy. Slight erythema was observed at the bilateral angles of the mouth, consistent with angular cheilitis. A non-tender, non-indurated lesion measuring 0.5 × 0.5 cm was identified on the lower right buccal sulcus over the premolar region, morphologically resembling an irritation fibroma, likely secondary to ill-fitting denture pressure. An oral swab was collected from the bilateral angles for Gram staining and Candida culture on Brilliance Candida Agar™ (BCA, Oxoid, UK). An expectorated oral rinse sample (20 ml saline) was obtained, centrifuged at 9600 rpm at 4°C for 10 minutes, and the resulting pellet (100 μl) was cultured for Candida isolation. Gram staining of the swab revealed scanty Gram-positive and Gram-negative bacteria and epithelial cells, with no evidence of blastoconidia or hyphal filaments. Primary cultures from both the oral swab and oral rinse yielded dark blue colonies along initial streak lines on BCA after 48 hours of incubation at 37°C. Colonies were subcultured onto fresh BCA and Sabouraud’s Dextrose Agar (SDA) plates, incubated at both room temperature and 37°C. On SDA, smooth, mucoid, light orange to beige colonies were observed at both temperatures; on BCA, similar colonies were seen at room temperature, while dark blue pigmentation was observed at 37°C. Yeast growth was faster at room temperature compared to 37°C on both media. Gram stain of the pure culture demonstrated round-to-oval yeast morphology. The isolate was designated as *C. calyptogenae* strain D1.\n\nSpecies-level identification was achieved via polymerase chain reaction (PCR) amplification and sequencing of the internal transcribed spacer (ITS) region and the D1/D2 domain of


A man with a weak immune system stayed infected with the COVID-19 virus for 189 days. Even after treatment, the virus kept coming back, and tests showed it was the same strain each time. This wasn’t a new infection — it was the same virus returning. Doctors used medicines like dexamethasone, remdesivir, and IV immune shots to help him. His body slowly got better, and by day 189, the virus was no longer detectable. Tests confirmed the virus didn’t change — it stayed the same. He got the vaccine later, and after that, his tests came back negative. Now he’s getting stronger and can do more activities.


A 58-year-old man with weakened immunity due to lymphoma treatment developed a long-lasting SARS-CoV-2 infection that lasted for 189 days. Even after initial treatment, the virus kept coming back in the same form, as confirmed by genetic testing showing the exact same strain each time. This was not a new infection with a different virus, but a relapse of the original virus. The patient had a cough, fever, and breathing problems that returned multiple times, requiring hospital visits and treatments like dexamethasone, remdesivir, and intravenous immunoglobulin. His immune system was weakened by prior chemotherapy and rituximab, which likely contributed to the prolonged infection. Viral culture and PCR tests showed the virus remained detectable for months, and even after treatment, the virus was still present until day 189. Once the infection was fully cleared, he received the COVID-19 vaccine, and follow-up tests showed no virus. His symptoms gradually improved, and he is now able to do more physical activity. The case shows that some immunocompromised patients can have very long-lasting viral infections that require a combination of treatments to manage.


{
    "proficient_health_literacy": "A 58-year-old Caucasian male with a history of follicular lymphoma, previously treated with six cycles of bendamustine and rituximab followed by maintenance rituximab, presented prior to widespread COVID-19 vaccination with a one-week course of cough, low-grade fever, and systemic malaise. Oropharyngeal swab testing was positive for SARS-CoV-2, and he was managed outpatient without hospitalization. Twenty-seven days later, he developed hypoxemia requiring hospital admission. Initial nasopharyngeal (NP) swab was negative, and high-resolution computed tomography (CT) revealed recurrent ground glass opacities and bilateral interstitial pneumonia, consistent with COVID-19. Laboratory findings included severe lymphopenia (0.1 × 10⁹/L, normal: 0.7–3.5 × 10⁹/L), elevated C-reactive protein (57.0 mg/L, normal: 0.0–8.0 mg/L), and markedly increased ferritin (2047 μg/L, normal: 30–500 μg/L), indicating significant inflammatory and immune dysregulation. He responded initially to dexamethasone 6 mg daily for 10 days; however, recurrent hypoxemia and progressive radiographic changes led to a diagnosis of organizing pneumonia as a post-COVID-19 sequelae. Bronchoscopy was declined, and oral prednisone 50 mg daily was initiated with a planned taper. On day 90 (73 days post-admission), following prednisone reduction to 10 mg, he developed new pyrexia and relapse of hypoxemia. Repeat NP swab RT-PCR was positive (Ct 18.7), and bronchoscopy was performed. Bronchoalveolar lavage (BAL) demonstrated both RT-PCR (Ct 18.7) and culture positivity (1.17 × 10⁴ pfu/mL) for wild-type SARS-CoV-2, belonging to the G clade, B.1.160 sublineage, with no growth of bacteria, mycobacteria, other viruses, or fungi. Histopathology of transbronchial biopsies revealed active pneumonitis with focal organizing pneumonia and patchy interstitial fibrosis, confirming a clinical


A 54-year-old man had a sudden heart attack, his heart stopped, and he needed CPR and medicine to restore blood flow. Doctors used a clot-busting drug and placed stents in his heart arteries to fix the blockage. He ended up in the heart care unit with a weak heart and severe muscle damage. The muscle damage was caused by a cholesterol medicine (atorvastatin) he was taking, so they stopped it. He needed help to filter his blood because his kidneys weren’t working well, and had to get dialysis. His muscles were damaged so badly that a muscle biopsy was done. After recovering, he was finally released to a regular hospital room.


A 54-year-old man had a severe heart attack (AMI) that led to cardiogenic shock and cardiac arrest. He required cardiopulmonary resuscitation, fibrinolysis with tenecteplase, and successful coronary angiography with stents placed in key heart arteries. He was admitted to the coronary care unit (CCU) with deep sedation, mechanical ventilation, and a SOFA score of 7, indicating serious organ dysfunction. He developed post-extubation complications including delirium, stridor, and a pneumothorax, which required reintubation. During his hospital stay, he received medications that can cause muscle damage, including haloperidol, olanzapine, and hydrocortisone. Shortly after reintubation, he developed severe rhabdomyolysis — a condition where muscle breakdown releases harmful substances into the blood — linked to his atorvastatin medication. His creatine phosphokinase (CPK) levels rose over 10 times normal, peaking five days later, prompting the discontinuation of atorvastatin. He also developed kidney failure (oliguria), requiring temporary hemodialysis. After recovery, he was successfully extubated and discharged to a general hospital room. The rhabdomyolysis was directly tied to atorvastatin use, which was stopped due to the severe muscle damage.


{
    "proficient_health_literacy": "A 54-year-old male presented with acute myocardial infarction (AMI) complicated by cardiogenic shock and cardiac arrest, requiring immediate advanced airway management in the emergency department. Tenecteplase 0.5 mg/kg was administered, with an ischemic time of 1 hour 40 minutes, and no reperfusion was achieved during the initial intervention. The patient experienced two episodes of pulseless tachyarrhythmias, each requiring defibrillation with 200 J biphasic shocks, advanced cardiopulmonary resuscitation (CPR), and intravenous amiodarone 300 mg to restore spontaneous circulation. Total duration of cardiac arrest was approximately 11 minutes.\n\nRescue coronary angiography revealed significant coronary artery occlusion, resulting in the placement of a medicated stent in the anterior descending artery and an unmedicated stent in the first diagonal artery. Post-procedural coronary flow was confirmed with a final TIMI flow grade of 3 and a blush grade of 3, indicating adequate reperfusion. The patient was admitted to the coronary care unit (CCU) in a state of deep sedation, under mechanical ventilation, with clinical evidence of cardiogenic shock and a SOFA score of 7, reflecting moderate organ dysfunction.\n\nPost-extubation complications included delirium, stridor, and iatrogenic pneumothorax, necessitating reintubation 48 hours after initial extubation. During this period, the patient received medications known to induce myositis, including intravenous haloperidol (5 mg intermittent doses, cumulative 30 mg), olanzapine (cumulative 20 mg), and hydrocortisone (200 mg). Subsequently, the patient developed septic shock, prompting initiation of broad-spectrum antibiotic therapy with vancomycin and meropenem at full initial doses, adjusted according to renal function, for six days as treatment for nosocomial pneumonia.\n\nAtorvastatin was continued enterally at a fixed dose of 80 mg every 24 hours for a total duration of 15 days. Two days after reintubation (10 days post-admission to CCU), serum creatine phosphokinase (CPK) levels rose to more than 10 times the upper limit of normal, peaking five days later, at which


A 24-year-old woman had a big, growing lump on her left upper back and shoulder that caused severe pain and made her unable to use her left arm. She had been treated before for a similar problem in the same area, and had surgery and chemo back then. The lump kept getting worse, and her wound wouldn’t heal. Doctors tried chemo several times, but it didn’t work. She refused an amputation of her arm, so she came to our hospital. When she arrived, the lump was huge, bleeding, and smelly. Tests showed it was cancer called Ewing’s sarcoma, and it had spread into the muscles but not into her arm joint or chest. She had surgery to remove the entire lump and surrounding tissue, including part of her shoulder blade and muscles. The area was cleaned and covered with a flap of skin from her back to close it. After surgery, she got radiation and chemotherapy, and also had a special treatment to help her body recover. Now, after 3 years, she has no signs of cancer, can use her left arm normally, and is back to her regular work.


A 24-year-old woman was diagnosed with Ewing’s sarcoma in her left scapula (shoulder blade) and had previously undergone surgery and chemotherapy. Over time, the tumor grew large, causing a massive, bleeding mass on her left upper back and shoulder, severe pain, and inability to use her left arm. The tumor was so large that it caused an open ulcer that wouldn’t heal. After multiple failed treatment attempts and being offered a limb amputation, she refused and was referred to our hospital. There, she received a surgery to remove the entire tumor, including part of the shoulder blade, surrounding muscles, and skin, with no cancer cells left behind. Before surgery, she received antibiotics, blood transfusions, and treatment to stop the tumor’s blood supply. After surgery, she received radiation therapy and chemotherapy, followed by a stem cell transplant to help her body recover. She has been disease-free for three years and now has full use of her left arm and is back to her normal work activities.


{
    "proficient_health_literacy": "A 24-year-old female presented with a massive fungating mass over the left upper back and shoulder region, characterized by active bleeding and foul-smelling purulent discharge from a large, non-healing ulcer. The lesion had been progressively enlarging over the prior two years, with an insidious onset of swelling. An incisional biopsy performed one year prior yielded a provisional diagnosis of Ewing’s sarcoma (ES) of the left scapula, prompting initiation of chemotherapy and subsequent surgical resection after three months of chemotherapeutic intervention. However, the surgical wound failed to heal, resulting in a rapidly expanding ulcer that persisted despite treatment. Neoadjuvant chemotherapy was initiated to shrink the tumor, but due to poor response—manifested by continued progressive growth and lack of tumor reduction—the regimen was modified multiple times over nine months without clinical benefit. Given the extensive size, invasive nature, and associated complications, multiple referral centers recommended forequarter amputation of the left upper limb, which was declined by the patient. She was ultimately referred to our institution for definitive management.\n\nOn presentation, magnetic resonance imaging (MRI) of the shoulder and upper back revealed a large, heterogeneous lesion measuring 18 cm × 27 cm × 26 cm, with T1 isointense and T2 heterogeneous high-signal intensity, consistent with a highly cellular, necrotic, and cystic tumor. The imaging demonstrated multiple fluid levels, degenerative cystic changes, hemorrhagic foci, areas of necrosis, and significant infiltration of periscapular musculature. Computed tomography (CT) scanning confirmed an ill-defined, heterogeneous tumor with prominent cystic components and gross osteolysis of the scapular bone, while no evidence of involvement was observed in the shoulder joint, chest wall, or brachial plexus. The axillary vascular bundle was displaced anteriorly without signs of vascular infiltration. Whole-body positron emission tomography-CT (PET-CT) scan showed no evidence of pulmonary or distant metastatic disease, supporting a localized, primary malignancy.\n\nHistopathological examination of a needle biopsy confirmed the diagnosis of Ewing’s sarcoma, demonstrating sheets of small, round, uniform cells with scant cytoplasm, separated by fibrous strands, and exhibiting minimal stromal component and few mitotic figures. Immunohistochemical staining was positive for CD99, a hallmark marker of Ewing’s sarcoma,


A 25-year-old man got into a fast car crash and hurt his wrist badly. His hand was stuck against the steering wheel, which broke the bone in his wrist. He was in extreme pain, even with pain medicine, and couldn’t have anyone touch his arm without it hurting. To fix the pain without putting him to sleep, doctors used a needle guided by ultrasound to inject numbing medicine into the nerves in his shoulder area. This made his arm completely numb and pain-free. After that, they were able to fix the broken bone without him feeling any pain. He went home the same day with a splint and will see a doctor for follow-up. The next day, he said his arm felt normal — no numbness or tingling.


A 25-year-old man came to the emergency department after a high-speed car crash. He had a Colles fracture in his right wrist, caused when his hand hit the steering wheel during the collision. Despite taking strong pain medications, he continued to have severe pain and couldn't tolerate having his wrist moved. To control the pain without using sedation, doctors performed an ultrasound-guided nerve block called a CCBPB. This block numbs the nerves in the upper arm, providing strong pain relief. After the procedure, the patient had complete numbness in his right arm and reported no pain at all. The broken bone was successfully realigned without further pain. He was given a splint and sent home with follow-up care. The next day, he reported no numbness, tingling, or weakness, and felt fully recovered.


{
    "proficient_health_literacy": "A 25-year-old male with no significant past medical history presented to the emergency department via ambulance following a high-speed motor vehicle collision in which he served as a restrained driver. During impact, he braced his outstretched right hand against the steering wheel, resulting in a traumatic injury to the wrist. On arrival, vital signs were stable, but the patient exhibited profound distress, reporting pain at 10/10 on the numeric rating scale. Physical examination revealed a grossly deformed right wrist with prominent dorsal swelling and severe tenderness to palpation, with no signs of neurovascular compromise. Radiographic evaluation demonstrated a transverse fracture of the distal radius with dorsal angulation of the distal fragment—consistent with a Colles fracture—and an associated ulnar styloid fracture.\n\nDespite administration of multimodal analgesia including intravenous opioids and nonsteroidal anti-inflammatory drugs (NSAIDs), the patient continued to experience intractable, severe pain, with absolute intolerance to radial manipulation, which precluded safe and effective manual reduction. To avoid the need for procedural sedation, an ultrasound-guided costoclavicular brachial plexus block (CCBPB) was performed as a targeted regional anesthesia strategy to achieve dense surgical anesthesia of the upper extremity and facilitate fracture reduction.\n\nInformed consent was obtained. The patient was monitored via continuous cardiac telemetry and had intravenous access established. He was positioned supine with the right arm abducted to 90 degrees to optimize anatomical exposure by stretching the pectoralis major and minor muscles, thereby bringing the costoclavicular brachial plexus into a more superficial and accessible position. Standard sterile technique was maintained throughout the procedure. A high-frequency linear ultrasound probe was positioned transversely just inferior to the midpoint of the right clavicle within the infraclavicular fossa, with the beam angled slightly cephalad to visualize the costoclavicular space posterior to the clavicular body. The costoclavicular brachial plexus cords were identified in the region lateral to the axillary artery and situated between the subclavius and serratus anterior (upper slips) muscles. Using an in-plane, lateral-to-medial approach, a 22-gauge, 50-millimeter echogenic needle was advanced between the lateral and posterior cords of the brachial plexus. Twenty milliliters of 0.5% rop


Ms. B is an 86-year-old woman who came to the hospital with a four-day history of not being able to move her bowels, not eating, feeling sick, and vomiting. She had pain in her belly, especially after eating, and her stomach was swollen. She had a history of some health problems like cancer of the skin (Kaposi sarcoma), high blood pressure, joint pain, and low vitamin D. She had had a C-section and a tonsil removal before. She lived alone but could still take care of herself.

When checked, her belly was swollen and painful, especially on the lower side. Her blood tests showed signs of infection and a slightly swollen liver, which means something was blocking the flow of bile. Her kidneys were a little affected, likely because she wasn’t eating much and was dehydrated. Her urine was normal.

A scan showed two big gallstones — one stuck in the first part of the small intestine (duodenum) and one in the end of the large intestine (colon). The gallbladder was swollen and had gas, which means it was leaking into the intestines. This is called a gallstone fistula. The doctor diagnosed her with Bouveret syndrome and gallstone coleus.

She got IV fluids and a tube put in her nose to drain her stomach. She started antibiotics to fight infection. The doctors decided to do an open surgery (not laparoscopy) because the stones were big and hard to reach, and there was likely scar tissue. During surgery, they found two places where the stones were blocking the intestines. They tried to push one stone into her stomach but couldn’t. They cut open the first part of the small intestine and removed the stone. They also opened the end of the large intestine and removed the second stone. There was no cancer or serious damage found. The cuts were closed with stitches, and the small intestine was reinforced with a piece of healthy tissue.

The surgery went well. She didn’t need extra help like breathing machines or heart medicine. Her diet was slowly restarted. She was sent home to her family and will keep checking in with a general surgery doctor.


Ms. B is an 86-year-old Italian woman who came to the emergency department with worsening bowel blockage. She had been experiencing four days of severe abdominal pain, nausea, vomiting, loss of appetite, and trouble passing stool. Her medical history includes Kaposi sarcoma, high blood pressure, joint pain (osteoarthritis), and low vitamin D. She had previously had gallbladder inflammation but never had surgery to remove it. She also had a caesarean section and tonsillectomy. She lived alone but could care for herself.

On exam, her vital signs were normal, but her abdomen was swollen and tender, especially in the lower part. Bowel sounds were still present. Lab tests showed mild signs of inflammation and early kidney issues due to dehydration. Liver tests showed a pattern consistent with a blockage in the bile flow. The CT scan found two large gallstones — one in the first part of the small intestine (duodenum) and one in the lower large intestine (distal colon). The gallbladder was inflamed and had gas, which suggested a connection between the gallbladder and the intestine (a fistula). The common bile duct was enlarged, confirming the diagnosis of Bouveret syndrome with gallstone coleus.

She was given IV fluids, antibiotics, and a tube to drain stomach contents. A laparotomy (open surgery) was performed because laparoscopy was too risky due to the stones and possible scar tissue. During surgery, both stones were found and removed — one from the duodenum and one from the sigmoid colon. The duodenal stone could not be moved, so it was removed by cutting open the first part of the small intestine. The colon stone was removed after making a small incision. There was no sign of a serious infection or tumor. The area around the gallbladder and duodenum showed signs of inflammation, which suggested a possible connection between the gallbladder and the intestine.

No gallbladder removal or bile duct surgery was done because the exact anatomy was unclear and the patient had many health problems that made those procedures too risky. Her recovery after surgery was smooth. She did not need extra support like breathing or heart medications. Her diet was gradually restarted, and she was discharged to her family. She is now being followed up in a general surgery clinic.


{
    "proficient_health_literacy": "Ms. B is an 86-year-old Italian woman with a complex medical history including Kaposi sarcoma, hypertension, osteoarthritis, and vitamin D deficiency. She presented to the emergency department with a four-day history of obstipation, anorexia, nausea, vomiting, worsening colicky abdominal pain, and postprandial reflux. Her surgical history includes a lower abdominal midline cesarean section and tonsillectomy; she lives independently and has no significant functional limitations. On physical examination, vital signs were normal, but the abdomen was distended, tender on palpation and percussion, with localized guarding, particularly in the lower quadrant. Bowel sounds were present, suggesting preserved peristalsis despite obstruction.\n\nLaboratory findings revealed a mildly elevated white cell count of 15.6 × 10⁹/L (normal: 4.0–11.0 × 10⁹/L) and C-reactive protein of 67 mg/L (normal <6.0 mg/L), indicating acute inflammation. Liver function tests showed bilirubin of 25 μmol/L (normal 2–20 μmol/L), alanine aminotransferase (ALT) of 18 U/L (normal <33 U/L), alkaline phosphatase (ALP) of 135 U/L (normal 30–110 U/L), and gamma-glutamyl transpeptidase (GGT) of 56 U/L (normal <56 U/L), consistent with an obstructive liver pattern. Serum creatinine was 99 μmol/L (normal 45–90 μmol/L) and urea was 8.6 mmol/L (normal 2.5–7.5 mmol/L), reflecting mild acute kidney injury secondary to reduced oral intake and dehydration. Electrolytes were within normal limits, and urinalysis was unremarkable.\n\nAbdominal computed tomography (CT) demonstrated two gallstones: one measuring 3.0 cm lodged in the proximal duodenum and another 3.3 cm located in the distal sigmoid colon. The gallbladder was contracted and inflamed, with gas detectable within the biliary tree (pneumobilia), suggesting a fistulous communication between the gallbladder and gastrointestinal tract. The common bile duct


A 43-year-old man has had a long problem with a type of white blood cell called eosinophils for 13 years. This has caused him to have shortness of breath, skin rashes, joint pain, stomach issues, and even problems with his breasts and kidneys. His breasts got swollen and painful, so he had surgery to remove both. His kidneys showed damage that needed treatment. He was given steroids to help his body calm down, and after a few days of strong IV steroids, his breathing and lung problem got better. Now he takes steroids every day to keep his symptoms under control. His condition is stable, and he can live a normal life with this treatment.


A 43-year-old Chinese man has had a 13-year history of high levels of a type of white blood cell called eosinophils, along with shortness of breath for the past 7 days. Over the years, he has had a range of symptoms including stomach problems, skin rashes (like eczema and vitiligo), joint pain, breast inflammation, and kidney issues. The chronic breast inflammation was so severe that he needed a bilateral mastectomy. A bone marrow biopsy confirmed the eosinophilia, and a kidney biopsy showed a condition called focal segmental glomerulosclerosis, which is a type of kidney disease. He has been treated with steroids, starting with intravenous methylprednisolone for 3 days, followed by oral steroids at the same dose. After treatment, a chest CT scan showed improvement in his lung condition. He is now on a long-term oral steroid regimen and his condition is stable. Steroids help control his symptoms, but symptoms often return when the medication is stopped. He also had episodes of high blood pressure and protein in his urine, which were signs of nephrotic syndrome, but these have improved with treatment.


{
    "proficient_health_literacy": "A 43-year-old Chinese male with a 13-year history of peripheral blood eosinophilia and progressive respiratory symptoms presenting with exertional dyspnea for 7 days was admitted to our institution. His initial presentation in August 2005 revealed a white blood cell count of 8.5 × 10⁹/L with 24.2% eosinophils (2 × 10⁹/L), prompting evaluation for eosinophilic disorders. Bone marrow biopsy demonstrated 13.5% eosinophils, predominantly with normally segmented rod nuclei, consistent with chronic eosinophilic infiltration. Upon initiation of oral triamcinolone (4 mg, three times daily), eosinophil counts rapidly normalized, indicating a strong corticosteroid-responsive phenotype. However, after a 6-month taper and eventual discontinuation, progressive hyperplastic and nodular changes developed in both breasts, accompanied by abnormal lactation and bilateral axillary lymphadenopathy, leading to a diagnosis of chronic mastitis. Bilateral mastectomy was performed in January 2006, with postoperative histopathology revealing male breast development and severe chronic interstitial inflammation characterized by dilatation of mammary ducts and dense eosinophilic infiltration.\n\nOne month later, the patient presented with trunk and limb joint pain, movement dysfunction, and a worsening erythematous skin rash. Treatment with dexamethasone and prednisone was initiated, and briefly, an herbal extract (Tripterygium wilfordii) was administered due to its anti-inflammatory properties, but was discontinued owing to severe treatment-related alopecia. Joint symptoms gradually improved, allowing functional recovery and return to work.\n\nIn April 2017, spontaneous bilateral lower extremity edema emerged, with clinical features consistent with nephrotic syndrome: blood pressure of 150/100 mmHg, plasma albumin of 15.6 g/L, low-density lipoprotein of 6.87 mmol/L, and 24-hour urinary protein excretion of 14.78 g/d. A renal biopsy confirmed focal segmental glomerulosclerosis (FSGS), non-specific type, a histopathological pattern commonly associated with chronic eosinophilic inflammation and immune dysregulation. Repeat bone marrow aspiration confirmed persistent eosinophilia, though qualitative polymerase chain reaction (PCR)


A 4-month-old boy came to the hospital with a lump on his head that was swollen, painful, and leaking pus. The lump got bigger and turned into a sore, and doctors found tiny worms inside it. Even after giving antibiotics and removing the worms, the boy still had fever and pus. X-rays and a 3D scan showed the bone around the lump was infected. The doctors changed the antibiotics and gave them for six weeks, plus used a skin flap to cover the area. After all this, the boy started feeling better and was sent home with more medicine and follow-up visits.


A 4-month-old male boy from a low-income area in Cartagena, Colombia, was brought to the emergency room with a painful, swollen bump on his skull that had pus draining from it. The bump had grown and turned into an open sore, and doctors found larvae inside it. He had a history of skin conditions like seborrheic dermatitis and fungal hair disease. He was given antibiotics at first, but the infection did not improve. The lesion worsened, and despite removing the larvae surgically, the boy continued to have fever, pain, and drainage. A skull X-ray showed a bone breakdown, and a 3D CT scan confirmed that the infection had spread to the outer part of the skull bone (osteomyelitis). The treatment was changed to include clindamycin and ivermectin, and he received antibiotics for six weeks, followed by four weeks of rifampicin. A skin flap surgery was also done to cover the damaged area. Tests for HIV were negative. After treatment, the boy’s symptoms improved, and he was discharged with ongoing antibiotic therapy and follow-up visits.


Male patient, 4 months old, from a low-income neighborhood in Cartagena de Indias, Colombia, with a prior history of seborrheic dermatitis and tinea capitis, presented to the emergency department with a one-week history of fever accompanied by a nodular lesion localized on the parietal region of the skull. The lesion was characterized by significant edema, tenderness, pain, and spontaneous purulent drainage. Initial empiric therapy with cefalotin was initiated, but no clinical improvement was observed. Over the course of hospitalization, the lesion evolved into a 3 cm diameter ulcer, and at admission, Dermatophagoides hominis larvae were directly visualized within the ulcerated orifice. Surgical debridement was performed, resulting in the removal of approximately ten larvae. Despite this intervention, the patient continued to exhibit fever, purulent exudate, and persistent larval presence even after six days of antibiotic therapy. Consequently, a combination regimen of clindamycin and ivermectin was introduced. Imaging evaluation revealed a skull radiograph demonstrating an osteolytic lesion, with 3D reconstructed computed tomography confirming osteomyelitis affecting the outer parietal bone surface. The patient received a total of six weeks of clindamycin therapy and four weeks of rifampicin, in addition to surgical intervention involving a scalp flap. Human immunodeficiency virus (HIV) testing, including both primary and secondary assays, was performed and returned negative, ruling out HIV as a contributing factor. Clinical improvement was achieved following the combined antimicrobial and surgical approach, and the patient was discharged with continued outpatient antibiotic therapy and scheduled follow-up visits. The clinical course reflects a complex case of cutaneous larva migrans with secondary osteomyelitis, likely secondary to deep tissue invasion by D. hominis larvae, which may have been facilitated by compromised skin integrity due to preexisting dermatological conditions and potential immunological vulnerability. The persistence of infection despite initial antibiotic coverage underscores the importance of accurate parasitic identification and the need for targeted antimicrobial and surgical management in pediatric cases involving deep cutaneous and osseous involvement.


A very small baby born early had a lung problem where air got trapped in the chest. Even after putting in a tube to fix it, the air stayed and the lung kept collapsing. Doctors had to cut open the chest to find a small hole in the air pipe (bronchus) that was letting air in. They fixed the hole with a patch and stitched it closed. After that, the lung started to work better. The baby had to have this surgery twice because the hole kept leaking air. After both surgeries, the air stopped coming back, and the baby finally got better. He’s now home with a small machine to help breathe and uses only a little oxygen.


A preterm baby born at 27 weeks developed pneumomediastinum and pneumothorax, both of which did not go away even after inserting a chest tube. The pneumothorax kept coming back, and doctors eventually had to perform a thoracotomy to find and fix a tear in the bronchus. During the surgery, they found a 1 cm hole between the left bronchus and the carina, repaired it with a patch, and used stitches and medical glue to secure it. After the first surgery, the baby still had another episode of air leak, so they did a second thoracotomy at the same site and repaired it again. The hole was fixed, and no air leaks were found after the procedure. The baby also had a small heart issue (patent ductus arteriosus) that was managed during the surgery. After recovery, the chest tubes were removed, and the baby was discharged home on day 161 with a home ventilator and oxygen support.


{
    "proficient_health_literacy": "A 27-week 4-day preterm male infant, born via cesarean section from a dichorionic diamniotic twin pregnancy with a birth weight of 1135 grams, presented with severe respiratory distress following premature rupture of membranes at 27 weeks, accompanied by uterine contractions and vaginal bleeding. Antenatal corticosteroids were administered, and delivery was planned due to arrested labor. At birth, the neonate exhibited hypotonia and apnea, requiring immediate intubation within one minute due to respiratory failure with an uncuffed endotracheal tube. APGAR scores were 4 at 1 minute, 6 at 5 minutes, and 7 at 10 minutes. The infant was admitted to the newborn intensive care unit (NICU) where a diagnosis of respiratory distress syndrome (RDS) was established. Treatment included endotracheal administration of poractant alfa (200 mg/kg), parenteral ampicillin-gentamicin for broad-spectrum coverage, and caffeine citrate to mitigate apnea. Mechanical ventilation was initiated in assist-control mode with volume guarantee and a maximum inspiratory pressure of 20 cm/H₂O. Cranial ultrasound revealed no structural abnormalities. On day 3, the infant was extubated and transitioned to nasal intermittent positive pressure ventilation (NIPPV), but required reintubation due to recurrent respiratory failure. Antibiotic therapy was escalated to vancomycin-meropenem due to clinical deterioration. On day 5, the infant developed worsening acute hypoxic respiratory failure. Chest radiography demonstrated mediastinal pneumothorax, with follow-up imaging showing rapid progression of pneumothorax on the left side and rightward mediastinal shift. A chest tube was inserted through the left 5th intercostal space to manage the pneumothorax. Repeat imaging showed expansion of the left lung and air bronchograms on the right. Ten hours later, persistent acidosis and hypoxia were noted, with a subsequent chest x-ray confirming recurrence of left-sided pneumothorax. The chest tube was set to continuous suction, resulting in progressive resolution of the pneumothorax on serial imaging. On day 6, echocardiography revealed a 3 mm patent ductus arteriosus (PDA) with predominantly left-to-right shunting and evidence of pulmonary hypertension. Oxygen saturation was approximately 80%, and


A 40-year-old man who worked in construction suddenly lost strength in his right arm and leg six days before he went to the hospital. He didn’t have any injury or neck pain from hitting his head. His neck didn’t hurt, and he didn’t have diabetes or high blood pressure. He had smoked for 10 years. When doctors checked him, his brain and speech were normal, but his right side was weak — he couldn’t lift his right arm or stand on his right leg. His right leg had no feeling, and his right hand had weak touch. The doctors found that the problem was in the spine, specifically in the neck area, and it was called Brown-Séquard syndrome on the right side. The brain scan was normal, but the neck spine scan showed a blockage in the blood vessel that supplies the spine — a torn blood vessel (vertebral artery dissection). This blockage caused damage to the spinal cord. After three months of medicine to stop blood clots and prevent blood from sticking together (anticoagulation and antiplatelets), the blood vessel healed and the strength returned. He felt much better and could walk again. Doctors said he should keep coming back for check-ups, but he didn’t.


A 40-year-old man who was otherwise healthy suddenly developed weakness on his right side six days before coming to the hospital. The weakness started about 16 hours before admission and made it hard for him to lift his right arm or stand on his right leg. He had no history of neck injury, surgery, or infections, and had no diabetes or high blood pressure. He had smoked for 10 years.

Neurological tests showed that his brain and speech were normal, but his right side had significant weakness. His right arm had only mild strength, his right leg had no strength, and his left side was normal. Sensation to pain and temperature was reduced on the left side below the neck, and reflexes were weak. These signs pointed to a condition called right-sided Brown-Séquard syndrome at the C3 level of the spinal cord.

Brain scans (head CT and MRI) were normal. Cervical spine MRI showed swelling and damage to the right side of the spinal cord at the C1-C3 level, indicating a spinal cord infarction (blockage of blood flow). A high-resolution MRI scan (VISTA) revealed a tear in the vertebral artery on the right side at the same level, which is known as vertebral artery dissection (VAD). This dissection likely caused the blood clot that damaged the spinal cord.

The patient was treated with anticoagulation (to prevent blood clots) and antiplatelet medications (to reduce clotting) for three months. After this treatment, follow-up MRI scans showed that the spinal cord damage improved and the vertebral artery had begun to heal. His symptoms greatly improved, and he was able to walk again. He was discharged with a good recovery score and advised to follow up, though he chose not to.


{
    "proficient_health_literacy": "A 40-year-old male building worker presented with acute onset of right-sided body weakness, initially manifesting as inability to lift the right upper limb and inability to stand on the right lower limb, which began 16 hours prior to hospital admission. There was no history of trauma, neck manipulation, surgery, or prior infectious illness. The patient had no history of diabetes and was normotensive. He was a chronic smoker with a 10-year history of tobacco use. Neurologic examination revealed intact consciousness and speech, with normal cranial nerve function. Using the Medical Research Council muscle grading scale, the right upper proximal limb demonstrated muscle power of 4/5, the right distal limb 2/5, and the right lower limb 0/5; contralateral limbs were intact at 5/5. Sensory deficits included loss of joint position and vibration sense in the right lower limb, impaired position sense in the right hand, and reduced pain and temperature sensation on the left side below the C3 level. The right ankle reflex was diminished. These findings are consistent with a right-sided Brown-Séquard syndrome at the C3 level. Deep sensation was preserved on the left side of the body. The Kernig sign was negative. Laboratory evaluations—including hematologic, biochemical, and immunologic parameters—were within normal limits. Cerebrospinal fluid obtained via lumbar puncture was unremarkable. Head CT and MRI were normal, excluding intracranial pathology. Cervical spine sagittal T2-weighted MRI demonstrated spinal cord swelling with a hyperintense lesion at the C1–C3 level. Axial T2-weighted sequences confirmed hyperintensity of the right spinal cord, consistent with spinal cord infarction (SCI). High-resolution 3D volumetric isotropic turbo spin echo (VISTA) MRI revealed asymmetric narrowing of the right vertebral artery at the C1–C3 level, with an eccentric high-signal intensity lesion parallel to the vessel lumen, indicative of vertebral artery dissection (VAD) with intramural hematoma. This finding established a pathophysiological link between the VAD and the ischemic spinal cord injury. The patient was treated with a combination of anticoagulant (AC) and antiplatelet (AP) therapy for a duration of 3 months. Follow-up MRI demonstrated a significant reduction in the abnormal spinal cord signal intensity, and VISTA imaging confirmed


A 76-year-old man had pain in his right leg when walking, which meant his leg blood flow was blocked. Doctors found the blockage in the right leg artery using a scan. They fixed it with a small tube (stent-graft) placed inside the artery. After the fix, the man started having pain and swelling in his right thigh, but no fever or infection was found. Blood tests showed his body was inflamed, like it was fighting something. A scan showed swelling around the artery and signs of inflammation. Doctors gave him steroids to calm the swelling, and within 7 days, the pain went away. The steroid dose was slowly lowered over 3 weeks. A follow-up scan after 3 months showed the swelling and inflammation had mostly gone away. The fix worked and his leg pain is now better.


A 76-year-old man with pain in his right leg (claudication) was found to have a blockage in his right superficial femoral artery, confirmed by a CT scan. He had a history of high blood pressure, high cholesterol, and smoked in the past. Treatment involved endovascular therapy, where a stent-graft named Viabahn (25 cm, 5 mm diameter) was placed to open the blocked artery. During the procedure, ultrasound was used to guide the stent through the artery safely. After the procedure, the patient developed pain and swelling in his right thigh about 5 days later. Blood tests showed high levels of inflammation, and MRI scans showed swelling in the surrounding tissue and increased signal around the artery, suggesting inflammation around the stent. There was no sign of infection or blood clot. The doctors started steroid medication (prednisolone) to reduce the inflammation, and within 7 days, the symptoms went away. The steroid dose was slowly reduced over 3 weeks and stopped. Follow-up MRI scans showed that the swelling and inflammation had greatly improved over the next few months. The patient recovered well and his condition stabilized.


{
    "proficient_health_literacy": "A 76-year-old male with peripheral arterial disease classified as Fontaine Stage IIB presented with right leg claudication. He had a history of hypertension, dyslipidemia, and current smoking. Preoperative contrast-enhanced computed tomography (CT) demonstrated a complete occlusion of the right superficial femoral artery (SFA). Antiplatelet therapy was initiated with 100 mg/day aspirin and 75 mg/day clopidogrel. Digital subtraction angiography revealed a 16-cm chronic total occlusion of the right SFA. Endovascular treatment (EVT) was performed under intra-arterial heparinization (5000 units). A 6-French guiding sheath was introduced via the left femoral artery. Intravascular ultrasound (IVUS) was utilized to navigate through the true lumen and confirm vessel patency, with no evidence of major dissection observed during pre-dilatation. A 4-mm semi-compliant balloon was used for pre-dilatation, followed by deployment of a 25-cm Viabahn stent-graft (diameter 5 mm) and post-dilatation with a 5-mm non-compliant balloon. Final angiographic assessment showed no edge dissection and confirmed adequate luminal patency and hemodynamic flow. The patient experienced symptomatic improvement and was discharged after 4 days. However, 6 days post-procedure, he developed acute pain and localized swelling in the right thigh. Venous thrombosis was ruled out by duplex ultrasound. Laboratory evaluation showed no signs of systemic infection: negative blood culture, procalcitonin level of 0.1 ng/ml (normal ≤0.5 ng/ml), and no fever. Nevertheless, inflammatory markers were significantly elevated: white blood cell (WBC) count of 12,000 cells/μl (normal range 4500–7500 cells/μl) and C-reactive protein (CRP) of 11.83 mg/dl (normal ≤1.0 mg/dl). Magnetic resonance imaging (MRI) revealed extensive soft-tissue edema and a high perivascular T2 signal surrounding the right SFA, consistent with perigraft inflammation. The stent-graft remained patent, indicating that the inflammatory response was localized to the perivascular tissue rather than involving graft failure. The clinical


A 27-year-old woman who drank a lot of vodka every day for years came to the hospital because she was scared and heard voices, thinking people were trying to hurt her. She had been drinking for a while and had been treated before for withdrawal, but left early. When doctors gave her a medicine called chlordiazepoxide to calm her down, she got worse—she became confused, saw things, and heard voices. But when they switched to another medicine, lorazepam, she started feeling better and soon stopped having those scary thoughts. After stopping all the medicines, she felt normal and stayed that way for hours. She’s now in a program to stop drinking and hasn’t had any more problems.


A 27-year-old white woman with a long history of heavy alcohol use developed symptoms of withdrawal when she stopped drinking. She was admitted to another hospital for withdrawal but left before being fully discharged. When she came to our hospital, she was paranoid, believed people were trying to harm her, and heard voices. Tests showed no signs of other illnesses or drug use, and her symptoms were linked to her alcohol dependence. She was given chlordiazepoxide, a benzodiazepine used to treat withdrawal, but within hours of each dose, she became more confused, agitated, and started hearing and seeing things that weren’t there. This worsened her delirium. After stopping chlordiazepoxide, she was given lorazepam, which helped calm her and improved her mental state. By the next day, she was calm, thinking clearly, and no longer had hallucinations or paranoia. She remained stable over the next 10 hours and was referred to a program for alcohol treatment, where she did not have any further mental health issues and did not need more benzodiazepines.


{
    "proficient_health_literacy": "A 27-year-old Caucasian female with a established history of ethanol dependence presented to the emergency department (ED) for evaluation of possible psychosis in the context of ethanol withdrawal. Two days prior, she had been admitted to an external hospital for management of ethanol withdrawal, receiving intravenous fluids but not benzodiazepines (BNZs). She removed her intravenous line and left the facility prior to formal discharge. Her family subsequently brought her to our institution, reporting symptoms of paranoia and the belief that individuals outside her home were attempting to kill her. Her last known alcohol consumption occurred four days prior, and toxicology screening for ethanol, benzodiazepines, and barbiturates was negative in both serum and urine. She reported consuming at least five 'heavy pours' of vodka daily for several years, consistent with chronic heavy alcohol use. Physical examination revealed tachycardia (127–132 beats per minute), elevated blood pressure (143–149/102–103 mmHg), and mild tenderness on bilateral upper abdominal quadrant palpation. Despite these findings, she was calm, fully oriented, and exhibited organized thought processes, though she reported persistent paranoia involving family members intending harm and auditory hallucinations. A comprehensive medical workup for delirium was performed, including a normal complete blood count, a comprehensive metabolic panel showing mildly elevated transaminases [aspartate aminotransferase (AST) 94 U/L; alanine transaminase (ALT) 72 U/L], and a noncontrast computed tomography (CT) of the brain demonstrating mild diffuse cerebral volume loss exceeding age-matched expectations. These findings were attributed to chronic alcohol exposure and were not indicative of an independent neurodegenerative or infectious process. Urine and serum toxicology screens were negative for coronavirus (SARS-CoV-2), human immunodeficiency virus (HIV), and hepatitis B and C. The patient expressed a strong interest in achieving sustained sobriety. Initial management included oral lorazepam 2 mg, followed by initiation of chlordiazepoxide 25 mg twice daily due to persistent tachycardia and hypertension. Within two hours of each chlordiazepoxide dose, she developed acute confusion, agitation, and vivid visual and auditory hallucinations, including the perception of individuals on the other side of the door attempting to enter her room. After two doses (


A 76-year-old woman noticed a small, slow-growing spot on her left breast for 5 years. It started growing faster recently, but she didn’t feel pain or any other symptoms. The spot was about 10 mm by 8 mm, blue-gray and looked like tiny pearls. Doctors checked her body and found no signs of cancer spreading. Tests showed no cancer in her chest, lymph nodes, or other parts of her body. A small biopsy confirmed it was a type of skin cancer called pigmented superficial BCC. She had surgery to remove the spot with a 10 mm safe edge around it. The doctors checked the edges right after surgery and found no cancer left. She went home the second day after surgery and has been feeling fine. At a 3-month check-up, there was no sign of the cancer coming back or spreading.


A 76-year-old Asian woman had a slowly growing spot on her left breast for 5 years, with recent faster growth. She had no pain, itching, or other symptoms. She did not have a history of cancer or major health conditions like high blood pressure, heart disease, or diabetes. Her family and personal history of skin or breast cancer was negative, and she had no significant sun exposure or radiation exposure.

On exam, a 10 mm × 8 mm blue-gray, pearl-like spot was found on the breast, with slight surface erosion. The rest of her body was normal. Imaging tests — including breast ultrasound, chest CT, SPECT-CT, and lymph node ultrasound — showed no signs of cancer spreading to other parts of the body.

A biopsy confirmed the lesion was a type of skin cancer called pigmented superficial basal cell carcinoma (BCC). The cancer started in the top layer of the skin and had a characteristic appearance under the microscope.

The patient had surgery to remove the lesion, including the nipple and areola, with a 10 mm safety margin around it. During surgery, the doctors checked the edges of the removed tissue and found no remaining cancer cells. After the procedure, the patient was discharged on the second day and had a follow-up visit at 3 months. She remained symptom-free and showed no signs of cancer returning or spreading.