{
    "proficient_health_literacy": "A 27-year-old male presented to the Department of Spine Surgery with acute-onset neck pain, unilateral limb numbness, and proximal and distal muscle weakness. Symptoms began four days prior to presentation and were of sudden onset, with no history of trauma. A prior episode of transient sensory disturbance and mild weakness in the extremities occurred six years earlier, suggesting possible recurrent or chronic spinal cord involvement. Physical examination revealed localized tenderness over the paraspinal muscles at the C6-T1 spinous process, diminished sensory perception to light touch in the T1 dermatomal distribution, and preserved motor function with grade IV muscle strength in all four limbs. Laboratory evaluations, including coagulation studies, inflammatory markers (e.g., CRP, ESR), and tumor markers (e.g., CA-125, CEA), were all within normal reference ranges, excluding systemic inflammatory or neoplastic etiologies. Spinal radiography and conventional computed tomography (CT) demonstrated no evidence of bony erosion, lytic lesions, or pathological fractures. Enhanced cervical magnetic resonance imaging (MRI) revealed a homogenously enhancing epidural mass within the C6-T1 spinal canal, compressing the spinal cord and extending into the left C7-T1 foramen. On T1-weighted imaging (T1WIs), the mass appeared hypointense, consistent with high vascular content or fat suppression, while on T2-weighted imaging (T2WIs), it was hyperintense, indicating high water content and susceptibility to edema or hemorrhage. Additionally, a 0.5 cm × 0.5 cm × 0.6 cm heterogeneously enhancing hyperintense lesion was identified within the C7 vertebral body on T2WI, consistent with a benign vertebral hemangioma (VH), a vascular malformation characterized by abnormal proliferation of vascular endothelial cells within the bone marrow. Histopathological examination of the excised epidural mass revealed papillary proliferation of vascular endothelial cells with associated thrombus formation, confirming the diagnosis of intraparenchymal epidural hemangioma (IPEH). The patient underwent C6-T1 laminectomy with radical excision of the epidural mass. Postoperative follow-up at six months demonstrated complete resolution of neurological symptoms without recurrence. This case illustrates the clinical spectrum of IPEH, including its characteristic imaging features (T1 hypointensity, T2 hyperintensity


Two men who were healthy before got a serious problem after getting the second dose of the Pfizer COVID-19 vaccine, about three weeks later. They both felt sudden, severe tiredness and shortness of breath, even when not moving. Tests showed no active coronavirus in their bodies. Doctors found high pressure in their lungs using heart ultrasound and, in one case, a special test on the heart’s right side. This high lung pressure hurt their hearts and likely caused long-term damage. There was no sign of blood clots in their lungs. Both men now have trouble doing daily activities and likely have lasting heart problems. Their symptoms didn’t go away completely, and the lung pressure stayed high even after months.


Pulmonary hypertension in two previously healthy adult men occurred within three weeks of receiving the second dose of the Pfizer (BNT162b2) mRNA COVID-19 vaccine from different batches. Both men suddenly developed severe fatigue and shortness of breath during physical activity, even at rest, and their SARS-CoV-2 PCR tests came back negative. Doctors diagnosed the condition using heart ultrasounds and, in one case, a more detailed heart catheterization. The diagnosis showed high pressure in the lungs' blood vessels, which is a sign of pulmonary hypertension. Neither patient had blood clots in their lungs. Both cases resulted in lasting symptoms and likely permanent heart damage. The condition led to long-term functional limitations, and in one case, the patient also developed irregular heartbeats. No evidence of pulmonary embolism was found in either case.


{
    "proficient_health_literacy": "Two cases of vaccine-induced pulmonary hypertension are reported in previously healthy adult males following the second dose of the Pfizer BNT162b2 mRNA COVID-19 vaccine, with onset occurring within three weeks of vaccination across different lots. Case #1 involves a 49-year-old male physician-athlete with a BMI of 23, non-smoker, and a history of mild exercise-induced asthma managed with albuterol. He received Dose 1 in December 2020 and Dose 2 in January 2021. Three weeks post-Dose 2, he developed acute severe fatigue, flu-like symptoms, tachycardia, palpitations, orthostasis, right-sided chest pressure, and exertional dyspnea. SARS-CoV-2 PCR testing was negative at symptom onset. Initial transthoracic echocardiography showed normal left ventricular function (ejection fraction 65%), normal right ventricular size and function, and a maximal tricuspid regurgitation velocity (TRVmax) of 3.09 m/s, yielding an estimated right ventricular systolic pressure (RVSP) of 42 mmHg, interpreted as mild to moderate pulmonary hypertension. Laboratory findings included a brain natriuretic peptide (BNP) level of 22 pg/mL (within normal range, <900 pg/mL), elevated low-density lipoprotein (LDL) cholesterol, and hematocrit of 50%. Pulmonary CT angiography with 3D reconstruction of the pulmonary artery (PA) tree demonstrated no evidence of pulmonary emboli. Subsequently, the patient developed 15 lbs of fluid retention, generalized edema, neck pressure, headaches, and a sensation of 'being hung upside down,' consistent with jugular venous distention (JVD) and cerebral venous congestion. Resting oxygen saturation (SpO2) was 92%, and new-onset systolic and diastolic arterial hypertension developed. Symptoms were present at rest and worsened with exertion, with functional capacity limited to New York Heart Association (NYHA) Class 3–4. Serial echocardiographic follow-up over one year showed no progression in RVSP or right ventricular function. Symptoms and exercise tolerance improved to NYHA Class 1–2, with resolution of fluid retention, swelling, tachycardia, and hypertension, and SpO


A 21-year-old woman who is overweight had been feeling tired, dizzy, and sweating for a long time. She had episodes of passing out, especially when her blood sugar was too low. Doctors thought it might be a problem with her body making too much insulin, called an insulinoma. Her blood sugar was very low — down to 20 mg/dl — even after giving her sugar. She had been treated as a baby for a similar problem, and doctors found a gene mutation that causes her body to keep making insulin even when sugar is low. She was given medicine called diazoxide, which helped, but she stopped taking it because it caused unwanted side effects like extra hair and swelling. This time, doctors started her on two new medicines: octreotide and diazoxide again. These helped her blood sugar go up and her symptoms like dizziness and passing out went away. She now feels better, and doctors stress that she must keep taking her medicine and check in with a specialist regularly to stay healthy.


A 21-year-old woman with a history of obesity and low blood sugar since infancy presented to the emergency department with repeated episodes of dizziness, fainting, sweating, and lethargy. Her blood glucose was very low—20 mg/dl when first seen—and remained low even after receiving dextrose (a sugar solution) multiple times. She had previously been diagnosed as a baby with a condition called persistent hyperinsulinemic hypoglycemia of infancy, caused by a mutation in the glucokinase (GCK) gene, specifically a Val452Leu activating mutation. This mutation causes her body to produce too much insulin, leading to low blood sugar. She was once treated with diazoxide and octreotide, which helped control her symptoms, but stopped taking diazoxide due to side effects like increased hair growth and fluid retention. On this visit, she was given octreotide and diazoxide again, and her blood sugar improved, with levels rising to between 55 and 110 mg/dl by discharge. Doctors stressed the importance of continuing her treatment and seeing an endocrinologist regularly to manage her condition.


{
    "proficient_health_literacy": "A 21-year-old Caucasian female presented to an external emergency department with altered mental status following discovery of lethargy by family members. On arrival, her plasma glucose was 20 mg/dL, consistent with severe hypoglycemia. She was hospitalized and initiated on dextrose infusion (10% dextrose in water), yet remained hypoglycemic with capillary glucose levels persistently between 50 and 60 mg/dL. She was transferred to our facility on suspicion of insulinoma, as she was unable to recall her prior diagnosis of hypoglycemia. Historical records from our neonatal unit revealed a history of persistent hypoglycemia beginning in infancy, including episodes of seizures, syncope, dizziness, headaches, palpitations, and sweating, which were initially intermittent and variable in severity. These symptoms were reported to have onset at birth, with no formal investigation until age 12, when she experienced recurrent episodes. She remained seizure-free and asymptomatic until age 17, when a new syncopal episode prompted an inpatient evaluation for hypoglycemia. During this evaluation, fasting blood glucose was 47 mg/dL after a 2-hour fast, proinsulin levels ranged from 10.4 to 84.1 pmol/L (normal range: 0–10 pmol/L), and C-peptide was 3.1 ng/mL (normal range: 1.1–4.4 ng/mL). Insulin antibody and sulfonylurea screening were negative, ruling out autoimmune or drug-induced causes. Abdominal magnetic resonance imaging (MRI) did not identify any insulinoma, leading to a genetic investigation that revealed a heterozygous Val452Leu activating mutation in the glucokinase (GCK) gene. This mutation results in constitutive activation of glucokinase, a key enzyme in glucose sensing within pancreatic beta cells, leading to excessive insulin secretion even in the absence of elevated blood glucose. The patient was initially managed with diazoxide, a potassium channel opener that reduces insulin release by promoting beta-cell membrane hyperpolarization, resulting in clinical improvement. She was discharged on oral diazoxide 250 mg daily, but discontinued therapy due to adverse effects including hirsutism and fluid retention. On current admission, she received dextrose boluses and was placed on continuous 5% dext


A 67-year-old man had psoriasis on his feet that was well controlled. He started treatment for cancer in his stomach, called gastric adenocarcinoma, and took medicine for it for months. Two months before, he began a drug called pembrolizumab to fight the cancer. He started having joint pain in his fingers, toes, knees, and shoulder, with swelling and redness. His skin had psoriasis plaques, and his nails were damaged. Blood tests showed inflammation, but no signs of rheumatoid arthritis. The doctor found inflamed joints, especially in the knees and shoulder, and thought it was psoriatic arthritis. He first tried steroids, but the pain got worse. Then he added two medicines—leflunomide and methotrexate—which helped a little, but the symptoms came back when the steroids were reduced. So, the doctor added a stronger medicine called etanercept, which controls the inflammation and finally stopped the joint pain and swelling.


A 67-year-old man with a long-standing history of foot psoriasis that was well controlled had recently developed joint pain in multiple areas, including his fingers, toes, left shoulder, and knees. He had been treated for advanced stomach cancer that had spread to lymph nodes, and had previously received pembrolizumab for cancer treatment. Two months before his joint symptoms started, he began pembrolizumab, which is used to help the immune system fight cancer. His psoriasis was already known, and he had signs of psoriatic nail changes and swelling in his finger and toe joints (dactylitis). On exam, his joints were red and swollen, and blood tests showed high levels of inflammation markers like C-reactive protein and erythrocyte sedimentation rate. Tests for rheumatoid arthritis (like rheumatoid factor and anti-CCP) were negative, which helped rule out other types of arthritis. Joint fluid from his knee showed signs of inflammation, and imaging showed fluid buildup and swelling in the knees and shoulder. Initially, he was given methylprednisolone, a steroid, to reduce inflammation, but his symptoms got worse after one week. He then started leflunomide and methotrexate, which helped a little but symptoms came and went with steroid use. Because the condition was not responding well, his treatment was changed to include etanercept, a drug that blocks a specific protein involved in inflammation (a tumor necrosis factor inhibitor). This change led to better control of his psoriatic arthritis.


{
    "proficient_health_literacy": "A 67-year-old male with a history of well-controlled plaque psoriasis of the feet presented with a two-week history of progressive polyarthralgia and nail dystrophy. He was diagnosed with advanced gastric adenocarcinoma with distant lymph node metastases in March 2020. Endoscopic evaluation revealed a 3-cm ulcerofungating mass in the pre-pyloric antrum, histopathologically confirmed as moderately differentiated adenocarcinoma. Immunohistochemical analysis demonstrated negative staining for human epidermal growth factor receptor 2 (HER2, IHC 1+), Epstein-Barr virus, and deficient DNA mismatch repair (dMMR), characterized by retained nuclear expression of MSH2 and MSH6 and loss of MLH1 and PMS2. Abdominal computed tomography identified multiple enlarged lymph nodes in the para-aortic and aortocaval regions, consistent with nodal involvement. The patient received first-line palliative chemotherapy with capecitabine and oxaliplatin for 11 months, followed by second-line therapy with ramucirumab and paclitaxel. Despite this, progression of disease was observed after two months of ramucirumab and paclitaxel, leading to initiation of pembrolizumab (200 mg every three weeks) in June 2021 as third-line treatment, based on the tumor's dMMR status, which is associated with microsatellite instability and potential responsiveness to immune checkpoint inhibition. Prior to pembrolizumab therapy, his neutrophil-to-lymphocyte ratio (NLR) was 1.1 and prognostic nutritional index (PNI) was 50.5, indicating a relatively preserved immune and nutritional status. Two months after pembrolizumab initiation, laboratory findings showed a normal white blood cell count (7970/µL), with 72.6% neutrophils and 17.9% lymphocytes, an elevated erythrocyte sedimentation rate (ESR) of 89.0 mm/h, and a serum high-sensitivity C-reactive protein (hs-CRP) level of 2.3 mg/L, reflecting systemic inflammation. Serologic testing for autoimmune markers was negative for rheumatoid factor (RF) and anticyclic citrullinated peptide antibody (ACPA), excluding


A 75-year-old man had a fever and pain on his right side of the chest. Doctors found a big lump under his diaphragm (the muscle that covers the belly) that was about 10 cm in size. It was attached to the liver and couldn’t be easily separated during surgery. Because of this, they had to remove part of the liver and the diaphragm. The surgery took 8 hours and he lost a lot of blood, but he recovered well and was out of hospital in 14 days. After 1 year, there’s been no sign of the lump coming back. The doctors looked at the tissue and found it was a slow-growing tumor that looked like smooth muscle, even though it wasn’t clearly a known type. They named it a 'spindle cell tumor with smooth muscle features' because it had markers that match muscle cells. The tumor wasn’t spreading, and it didn’t grow fast, so it was not very dangerous.


A 75-year-old man came in with fever and pain on the right side of his chest. Imaging tests showed a large 10-cm tumor under his diaphragm, which was attached to the liver and hard to separate during surgery. Doctors initially suspected it might be a rare, possibly cancerous tumor from the diaphragm, such as a myxoid sarcoma or schwannoma, but couldn't rule out a benign cause. Blood tests showed mild signs of inflammation and abnormal levels, and a PET scan showed the tumor was active, but not extremely so. Because the tumor was stuck to the liver and near important blood vessels, the surgery had to be more extensive — including removal of part of the liver (right posterior segment) and the diaphragm. The operation took 8 hours and 10 minutes, with about 1,459 mL of blood lost. After surgery, the patient recovered well and was discharged after 14 days. The tumor was found to be just below the liver, touching the diaphragm but not fully connected. Under the microscope, it looked like a low-grade tumor, possibly a solitary fibrous tumor or perivascular epithelioid cell tumor, but tests for those didn’t come back positive. Instead, the final diagnosis was a spindle cell tumor with smooth muscle features, based on positive results for muscle markers like αSMA, desmin, and h-caldesmon. One year after surgery, there has been no sign of the tumor coming back.


{
    "proficient_health_literacy": "A 75-year-old male presented with fever and right-sided chest pain. Laboratory investigations revealed elevated inflammatory and metabolic markers: lactate dehydrogenase (LDH) 251 IU/L, alkaline phosphatase (ALP) 469 IU/L, gamma-glutamyl transferase (γ-GTP) 125 IU/L, creatinine 1.43 mg/dL, C-reactive protein (CRP) 3.04 mg/dL, squamous cell carcinoma antigen (SCC) 1.8 ng/mL, nerve-specific enolase (NSE) 21.6 ng/mL, and soluble interleukin-2 receptor (SIL-2R) 614 U/mL, suggesting a systemic inflammatory process or malignancy. Contrast-enhanced computed tomography (CT) identified a large, well-circumscribed, 10-cm mass located beneath the right diaphragm, with a smooth margin and heterogeneous, gradually increasing enhancement in both the tumor and adjacent liver parenchyma, particularly in regions adjacent to fatty tissue. The primary arterial supply was identified as the right inferior phrenic artery, supporting a sarcomatoid origin from the diaphragmatic mesenchyme rather than a benign lesion such as schwannoma. No evidence of pulmonary invasion was observed. Magnetic resonance imaging (MRI) demonstrated heterogeneous high signal intensity on T2-weighted imaging (T2WI) and diffusion-weighted imaging (DWI), with progressive, heterogeneous contrast enhancement consistent with CT findings, further indicating active tumor metabolism. FDG-positron emission tomography (FDG-PET) showed abnormal glucose uptake with a maximal standardized uptake value (SUVmax) of 4.6, which, while not extremely high, was sufficient to raise concern for a malignant process, particularly myxoid liposarcoma or other sarcomatoid tumors. Despite imaging suggesting a primary diaphragmatic origin, the possibility of hepatic adhesion was noted due to the tumor's proximity to the hepatic capsule and intraparenchymal space. Given the tumor's adherence to the liver and its close anatomical relationship with the posterior Glisson’s pedicles and segment 8 dorsal Glisson’s pedicle, a diaphragmatic resection was not feasible without risking vascular compromise or hepatic injury. Consequently, an extended right posterior segmentectomy with concomitant diaphragmatic


A 20-year-old man got trapped under a heavy steel frame while fixing a crane. He was bleeding badly from his lower belly, and doctors found serious injuries to his pelvis and bones. Even after trying to stop the bleeding and saving his life, his legs were too damaged to stay attached. Doctors had to cut off both legs — one above the knee on day 8, and the other at the hip on day 13. His body had so much damage that parts of his muscles died and had to be removed. To fix the open wound, doctors used skin from his thigh to cover the exposed bones in his pelvis. This skin stayed in place and helped heal. After months of healing and cleaning the wounds, his skin fully grew back. Now he can sit in a wheelchair, move on his own, and live at home with his parents. The rebuilt pelvis works well with his prosthetic legs.


A 20-year-old Japanese man was trapped under a 3-ton steel frame while working on a crane. He was rescued and arrived at the hospital with heavy bleeding from his lower right abdomen. His vital signs showed he was in shock, and his injuries were severe: his pelvis was broken, the bones in his lower back and hips were fractured, and there was damage to his spleen. Imaging showed bleeding from both internal iliac arteries, which was treated with a procedure to stop the bleeding. Despite efforts, blood loss continued, and the patient developed tissue damage in both legs. Because of the risk of massive bleeding and the extent of tissue death, doctors decided that amputating both legs was necessary to save his life. He had a right above-knee amputation on day 8 and a left hip disarticulation on day 13. Over the next several weeks, his wounds were cleaned multiple times due to infection, and parts of his muscles were removed. On day 112, a flap of skin from his thigh was used to cover the exposed pelvis, and over time, the wound healed. A skin graft was later applied to finish healing. He now uses a wheelchair and can move independently. The reconstructed pelvis allows him to wear prosthetics properly and live at home with his family.


{
    "proficient_health_literacy": "A healthy 20-year-old Japanese male sustained a catastrophic traumatic injury when trapped beneath a 3-ton steel frame during crane maintenance. Upon rescue, he presented with persistent hemorrhage from the right lower abdominal wound, and upon emergency department arrival, exhibited unstable hip mechanics. Vital signs included a respiratory rate of 22 breaths per minute, blood pressure of 97/65 mmHg, and a tachycardia of 140 beats per minute. His Glasgow Coma Scale score was E4 V5 M6, indicating moderate to severe altered mental status. Physical examination revealed active pelvic instability and ongoing exsanguination from the right lower abdominal wound. Immediate interventions included endotracheal intubation and aggressive fluid resuscitation. Computed tomography (CT) imaging demonstrated multiple severe pelvic injuries: splenic laceration, sacral fracture, sacroiliac joint separation, and comminuted fractures of the right pubis, ischium, and acetabulum. Empirical antibiotic therapy with vancomycin and meropenem was initiated to prevent sepsis. Transcatheter arterial embolization (TAE) was performed in the angiography suite to control pelvic hemorrhage; angiographic evaluation revealed extravasation from both bilateral internal iliac arteries, which were successfully embolized. However, bilateral external iliac arteries demonstrated thrombosis, indicating compromised distal perfusion. A SAM® Pelvic Sling™ (SAM Medical, Wilsonville, OR, USA) was applied to stabilize the pelvis and maintain anatomical alignment. Despite TAE, complete hemostasis was not achieved, prompting consultation with a vascular surgeon. Emergency ligation of the right external iliac artery was performed in the operating room, resulting in immediate hemostasis. The wound was then packed and sutured. Follow-up CT imaging revealed ischemic changes in the right lower limb, consistent with distal arterial occlusion. Given the patient’s young age, robust physiological reserve, and strong familial desire to preserve limb function, revascularization was pursued despite the risk of recurrent hemorrhage. A crossover graft using the axillary-femoral artery was performed to restore distal femoral perfusion. Subsequently, a retroperitoneal hemorrhage was identified, likely due to injury to the external iliac artery, prompting a second crossover graft utilizing the axillary-femoral vein. Concurrently, cystostomy and external


A 23-year-old man had a fever, no sense of smell, headache, and nausea a week before. Doctors said he had COVID-19 and treated him for 10 days at home. Two weeks later, he came back with fever every two days, feeling cold, then hot, then sweating. Tests showed he also had malaria (P. vivax), and his blood had a lot of clots (high D-dimer). He was given medicine for malaria: DHP for 3 days and primaquine for 14 days, as per local rules. He also got heparin to help stop blood clots. After 6 days, his fever went away and his blood tests got better. He’s now feeling fine and staying at home. Both COVID-19 and malaria can cause blood clots, so having both makes the illness worse. This shows why it’s important to check for both when someone has fever and trouble breathing, especially in areas where malaria is common.


A 23-year-old man first visited the hospital with fever, loss of smell, headache, and nausea. He was diagnosed with COVID-19 based on a nasal swab test, and treated at home for about 10 days. Even after being cleared, he still tested positive for the virus and continued to self-quarantine.

Two weeks later, he returned with recurring fever every two days, along with chills, fever, and sweating. His temperature reached 39.7°–40°C. The fever came and went, and even with paracetamol, it returned within hours. He also had muscle pain and weakness.

Lab tests showed high levels of inflammation and a marker called D-dimer, which can indicate blood clotting problems. A malaria test was done, and both the rapid test and blood smear confirmed he had a relapse of P. vivax malaria — a type of malaria he had before, during a trip to Papua.

Because he had both COVID-19 and malaria, doctors treated him for both. He took dihydroartemisinin-piperaquine for 3 days and primaquine for 14 days, following national malaria treatment guidelines. He also received paracetamol and heparin to help with fever and blood clotting. After six days of treatment, his symptoms went away and lab results improved.

This case shows that during the pandemic, people in malaria-endemic areas can get both COVID-19 and malaria at the same time. Both diseases can cause blood clotting issues, so having both can make the illness worse. Early diagnosis and prompt treatment are key to avoiding serious complications.


{
    "proficient_health_literacy": "A 23-year-old male patient presented to the Universitas Airlangga Hospital emergency department with a 5-day history of fever, anosmia, headache, and nausea. SARS-CoV-2 RNA was detected by RT-PCR amplification from a nasopharyngeal swab, confirming a diagnosis of COVID-19. Initial laboratory findings included lymphopenia, neutrophilia, thrombocytopenia, and elevated C-reactive protein (CRP), with a normal chest X-ray. The patient was managed according to the Indonesian National COVID-19 Treatment Guidelines, receiving favipiravir at 1600 mg every 12 hours on day 1, followed by 600 mg every 12 hours from day 2 to day 5, intravenous paracetamol 1000 mg every 8 hours, oral vitamin C 500 mg every 8 hours, and oral vitamin D 1000 IU daily. Despite this treatment, the patient remained PCR-positive after 10 days with no clinical symptoms and was discharged to continue self-quarantine at home.\n\nTwo weeks later, the patient returned with recurrent fever occurring every 2 days, characterized by a distinct chilling-fever-sweating cycle, with peak temperatures ranging from 39.7° to 40 °C. The fever was partially controlled by paracetamol but recurred within 6 hours, accompanied by malaise and myalgia. The next day, the fever resolved, and the patient was ambulatory with normal physical examination findings: body temperature 38 °C, blood pressure 112/72 mmHg, heart rate 93 bpm, respiratory rate 20 breaths/min, and oxygen saturation 98% on ambient air. Body mass index (BMI) was 22.5 kg/m² (height 170 cm, weight 65 kg). All other physical exam parameters were within normal limits.\n\nLaboratory analysis revealed a white blood cell count of 8750/µL with 76.3% neutrophils, 13.5% lymphocytes, and 0.6% eosinophils; hemoglobin 12.2 g/dL, platelet count 231,000/µL; CRP


A 52-year-old man from North Africa who smoked for 30 years came in with chest pain that got worse with activity. He had high blood pressure and bad cholesterol, and had ignored his symptoms for 10 years. His heart exam was normal, and his lungs and legs were fine. His heart’s main pumping chamber (left ventricle) was healthy — it was the right size and working well, even though one major blood vessel in his heart was completely blocked. The right side of his heart was also fine. Doctors found a major blockage in the main artery feeding the left side of the heart, and a narrow spot in the right coronary artery. He had surgery to fix it using grafts from his chest and leg. The surgery went smoothly, and he recovered well. He was out of hospital in 9 days. Six months later, he had no chest pain, no shortness of breath, and his heart was working normally again. His heart test results showed no signs of damage or trouble.


A 52-year-old North African man with a 30-year history of smoking and high blood pressure presented with unstable angina that had been worsening over the past few days. He had ignored his symptoms for 10 years, including chest pain and shortness of breath during activity. Tests showed a complete blockage in his left main coronary artery, with a significant narrowing in his right coronary artery. Surprisingly, his left ventricle — the main pumping chamber of the heart — was normal in size and function, despite the severe blockage. He underwent successful on-pump coronary artery bypass grafting (CABG) surgery, where blood flow was rerouted around the blocked arteries using grafts taken from his chest and leg. The surgery went smoothly, and he recovered well, being discharged after 9 days. At 6 months follow-up, he had no chest pain or shortness of breath, normal heart function, and a healthy physical exam. His heart rhythm and overall heart health were stable, with no signs of heart failure.


{
    "proficient_health_literacy": "A 52-year-old North African male with a 30-year history of tobacco smoking presented to our department with unstable angina of 24-hour duration, secondary to a total chronic occlusion of the left main coronary artery (LMCA), with no antegrade flow in the left anterior descending artery (LAD) and circumflex artery (Cx). He had a history of hypertension and dyslipidemia, with controlled blood pressure at 142/83 mmHg during clinical evaluation, and a body mass index of 25 kg/m². Physical examination revealed normal heart sounds, absent murmurs, clear lung auscultation, no peripheral edema, and normal carotid artery flow. Resting electrocardiogram (ECG) demonstrated normal sinus rhythm at 55 bpm without ST-segment elevation, but showed persistent anteroseptal Q waves and inverted T-waves in apical and lateral leads, suggesting prior myocardial injury or ischemia. Transthoracic echocardiography confirmed normal left ventricular (LV) size and systolic function, with an LV ejection fraction of 68%, normal segmental wall motion, and low LV filling pressures. Systolic pulmonary artery pressure was 24 mmHg, and right ventricular size and function were within normal limits, indicating preserved right heart function. Coronary angiography revealed total occlusion of the LMCA, with dominant right coronary artery (RCA) perfusing the left coronary territory via extensive collateral circulation, despite a significant stenosis in the RCA itself. This paradoxical preservation of left ventricular function, despite severe left main disease and extensive ischemia, suggests a robust compensatory collateral network and minimal ischemic myocardial damage. The patient was referred for elective on-pump coronary artery bypass grafting (CABG) two days post-angiography. Anesthesia was induced with cisatracurium besylate, midazolam, thiopental, and propofol, and a median sternotomy was performed for harvesting of the internal thoracic arteries (ITA) and saphenous vein graft (SVG). The right internal thoracic artery (RITA) was anastomosed to the left internal thoracic artery (LITA) to form a composite 'LITA-RITA-Y' graft configuration, enhancing graft viability and flow distribution. Cardiopulmonary bypass was established via aortic and


A woman had headaches for months, then got a stroke that only affected her senses, like numbness in her face and arm. Doctors first thought it was a virus, but her brain scans and fluid tests didn’t show that. Later, they found tiny worms in her brain fluid — specifically, a type of worm called Taenia solium — which means she had a brain infection from a parasite. Tests confirmed the worm was there, and her body made antibodies to fight it. After taking medicine to kill the worms, the amount of worm DNA in her brain fluid went down a lot. Her headaches got better, and after 3 months, she was feeling fine. The worms didn’t completely disappear, but the infection is now under control.


This study describes a woman in her 40s who had headaches for several months, which later turned into a pure sensory stroke — meaning she lost sensation in her face and arm but had no movement problems. Initially, doctors thought it might be a virus, so she was given antiviral medication, but her symptoms didn’t improve. An MRI and other brain scans were normal at first, but later imaging showed small lesions in her brain, and her spinal fluid pressure was very high. After treatment for possible blood clot issues, her headaches remained severe. Tests on her spinal fluid found a high white blood cell count and elevated protein levels. A key test called next-generation sequencing (NGS) detected DNA from a parasite called Taenia solium, which causes cysticercosis. This was confirmed by positive antibodies in her spinal fluid. The patient was treated with antiparasitic medication (praziquantel), and follow-up tests showed a big drop in the parasite DNA levels. Her headaches improved significantly, and after six months, she had no symptoms left. Although some brain lesions remained, the infection was successfully treated.


{
    "proficient_health_literacy": "A 44-year-old female factory worker presented with a 12-month history of recurrent, temporal and parietal headaches characterized by burst-like pain, initially evaluated at a local hospital in April 2016. Initial brain magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) were normal. Cerebrospinal fluid (CSF) analysis revealed a white blood cell count of 68 cells/μL and an intracranial pressure of 310 mmH₂O, prompting suspicion of viral encephalitis. She was treated with intravenous acyclovir (500 mg every 8 hours for 7 days), but symptoms remained unchanged. Three months later, in July 2016, she presented with worsening headache and paroxysmal numbness of the left face and arm, diagnosed as an ischemic stroke involving the right thalamus. She was initiated on oral aspirin 100 mg and atorvastatin 20 mg daily; numbness improved, but headache persisted. Five days prior to presentation at our institution, she returned to the local hospital due to severe headache on October 26, 2016, with lumbar puncture findings indicating CSF pressure >400 mmH₂O, white cell count of 40 cells/μL, and protein level of 1171 mg/L. Cerebral magnetic resonance venography (MRV) demonstrated underdevelopment of the right lateral sinus, with sinus thrombosis considered as a potential etiology. She was treated with low molecular weight heparin, resulting in partial headache relief. She was subsequently admitted to our hospital for further evaluation.\n\nThe patient had no significant past medical history, denied blood transfusions or consumption of raw food. Physical examination was unremarkable except for horizontal nystagmus. Laboratory testing revealed a mild elevation in eosinophil count (3.35%), with all other indices within normal limits. Serologic tests for HIV, syphilis, Herpes simplex virus types 1 and 2, tuberculosis (T-Cell spot test, purified protein derivative), and cryptococcal antigen (latex agglutination) were negative. Three lumbar punctures performed during admission confirmed persistently elevated intracranial pressure and increased white blood cell counts.\n\nCerebral MRA showed no abnormalities, while MR


A 25-year-old woman from Kuwait, who had her first baby and was not married to someone from her family, was healthy before pregnancy. She went to a private clinic for check-ups, but no ultrasounds were done. She didn’t have diabetes or any past health problems. At 31 weeks, she went to the hospital because her water broke after 3 hours. She was fine when she arrived — no fever, normal breathing, and her heart was okay. The baby was in a breech position (feet first), not in labor yet. The doctors gave her antibiotics to prevent infection and gave her medicine to help her baby’s lungs grow. After 8 hours, she started having labor pains, and the doctor found the cervix was fully open. The baby was born early — weighing 1570 grams — and had a score of 3 out of 10 at first (meaning it needed help). The baby had serious birth problems: legs fused together, unclear genitals, a hole where the bladder and bowel should be, and a tube connecting the windpipe to the esophagus. The baby was taken to a special care unit for help. Doctors found no major chromosome issues, but the baby had missing or fused bones, a single opening for urine, and a blocked part of the intestines. Surgery was done to fix the intestines and create tubes to feed the baby. The left kidney had many small bags, and the right kidney wasn’t seen (might be in a strange place). The baby stayed in the hospital for 123 days and was finally sent home to continue treatment in the USA. The parents agreed to share this story with doctors and pictures, with their full permission.


Mrs. RB, a 25-year-old Kuwaiti woman who was pregnant for the first time, had a normal pregnancy until she was admitted to the Maternity Hospital in Kuwait at 31 weeks of gestation. She had a 3-hour history of ruptured amniotic membranes, which means the sac surrounding the baby had broken. She was not known to have diabetes, and her medical and surgical history was normal. Her family did not have a history of diabetes.

At admission, she was healthy, with normal vital signs and no signs of infection or breathing problems. The baby was in a breech position (feet or buttocks down), and the pregnancy was confirmed to be at 31 weeks. She was given antibiotics to prevent infection and dexamethasone to help the baby’s lungs mature. After 8 hours, she started having labor pains, and the cervix was fully open. The baby was delivered by assisted breech delivery, weighing 1570 grams. The baby’s Apgar score was 3 at 1 minute and 9 at 5 minutes, which means it needed immediate medical support to start breathing.

The newborn had several serious birth defects, including fused lower limbs, ambiguous genitalia, a cloacal anomaly (a single opening for urine, stool, and sometimes waste), and a tracheoesophageal fistula (an abnormal connection between the windpipe and the esophagus). The baby was taken to the neonatal intensive care unit (NICU) for close monitoring and treatment. Tests showed the baby had a normal number of chromosomes (46 XX), but there were major structural problems in the bones and organs.

Surgery was needed to fix the bowel issues, including a blocked part of the small intestine and a blocked colon. The esophagus was tied off, and a feeding tube was placed to help the baby get nutrition. The kidneys were also affected — the left kidney had many cysts, and the right kidney was not visible, which may mean it was in an unusual position.

The baby stayed in the hospital for 123 days and was eventually discharged to continue treatment in the USA. The parents gave their consent for the case to be reported, including the use of medical images and details, after discussing it with the doctors.


{
    "proficient_health_literacy": "Mrs RB, a 25-year-old Kuwaiti woman with a primigravida history, married for 18 months to a non-consanguineous partner, presented at 31 weeks of gestation to the Maternity Hospital, Kuwait, with a 3-hour history of ruptured membranes. The pregnancy was spontaneous and had been managed in a private health care setting with no prior antenatal ultrasonographic surveillance; the patient provided no documentation of such imaging. There was no history of diabetes mellitus, and her surgical, medical, and gynecological history was non-contributory. On admission, she was afebrile, hemodynamically stable, with normal vital signs, clear lung sounds, and normal cardiac examination. Obstetric examination confirmed gestational age consistent with 31 weeks, a single fetus in frank breech presentation, and normal fetal heart activity. No signs of intrauterine distress were detected.\n\nThe patient was managed conservatively with prophylactic antibiotics to prevent ascending infection and administered a course of dexamethasone (typically 6 mg intramuscularly, repeated every 6 hours for 24 hours) to promote fetal lung maturation in anticipation of premature delivery. She was transferred to the antenatal ward for monitoring. Eight hours later, she was readmitted to the labor ward with onset of labor pains. Pelvic examination revealed complete cervical dilation (10 cm) and a frank breech presentation at station 1 cm below the ischial spine, indicating a clinically significant fetal position for delivery.\n\nAn assisted breech delivery was performed due to the non-reassuring fetal position and the premature gestational age. The newborn had a birth weight of 1570 g (approximately 3.46 lbs), and Apgar scores of 3 at 1 minute and 9 at 5 minutes were recorded, indicating initial compromise requiring immediate resuscitation. An endotracheal tube was inserted to secure the airway, and active neonatal resuscitation was initiated, including positive pressure ventilation and chest compressions as needed.\n\nThe neonate exhibited multiple congenital anomalies: bilateral lower limb fusion (syndactyly with complete fusion of the tibial and fibular segments), ambiguous genitalia, cloacal anomaly (a single, patent cloaca with malformation of the anorectal and urogenital tracts), and tracheoesophage


A 20-year-old woman had surgery to fix a curved spine and join the bones together using screws and hooks from T3 to T12. After the surgery, on day 2, she had a sudden drop in oxygen levels, so doctors did tests to make sure her lungs weren’t blocked by a blood clot. The tests showed no clot, but the scan found her heart was stretched and had a big hole in the wall between the two upper chambers — a hole that had been there all along but didn’t cause symptoms. They also found one of the screws was bent to the side and was very close to her main blood vessel (aorta). Doctors decided first to fix the heart hole, which was done safely and she recovered well. After that, they checked the screw again with special scans to make sure it wasn’t poking into or touching the blood vessel — and it wasn’t. Two years later, they safely removed the screw and the rest of the hardware. The spine stayed strong and straight, and no problems came back after that. Everyone involved, including heart and spine specialists, watched closely to make sure everything was safe.


A 20-year-old woman had surgery to correct a curve in her spine (scoliosis) and fuse the spinal bones from T3 to T12 using screws and hooks. After the surgery, on post-operative day 2, she experienced sudden drops in oxygen levels, which led to tests to check for a blood clot in her lungs. These tests were negative, but the CT scan showed that her right side of the heart was enlarged, indicating a large hole in the heart wall (atrial septal defect or ASD) that had been present but not causing symptoms before. During the same scan, a small problem was found with a screw at the left T10 level — the screw tip was very close to the aorta, the main blood vessel in the chest. Because the heart issue was more urgent, the medical team focused on fixing the heart first. She had successful surgery to repair the hole in her heart and recovered well. After that, a follow-up CT scan helped map the position of the screw. Additional imaging, including angiography and ultrasound, showed the screw was not inside or pressing on the aorta. Two years later, the team decided to remove the screw safely, with a vascular surgeon and interventional radiologist on standby. The spine was reopened, the screws were removed, and the fusion site was reinforced with bone graft. The patient has been followed up for two years with no signs of spine curve returning or complications.


{
    "proficient_health_literacy": "A 20-year-old female underwent posterior spinal deformity correction and spinal fusion for presumed adult idiopathic scoliosis, with posterior spinal instrumentation consisting of pedicle screws and hooks extending from T3 to T12. Preoperative evaluation, including electrocardiography (ECG), revealed no abnormalities, and her medical history was unremarkable, with normal physical activity levels including participation in sports. The anesthetic induction and surgical procedure were uncomplicated, with stable intraoperative neuromonitoring demonstrating consistent motor and sensory nerve potentials throughout the operation. Postoperative course was initially uneventful until post-operative day 2, when the patient experienced episodes of acute desaturation. This prompted evaluation with duplex ultrasound Doppler of the bilateral lower extremities and computed tomography pulmonary angiography (CTPA) to exclude pulmonary embolism. Both studies were negative for pulmonary embolism, but the CTPA revealed a right heart strain pattern and an enlarged right ventricular chamber, consistent with chronic volume overload. Subsequent two-dimensional echocardiography identified a large atrial septal defect (ASD), which had remained clinically asymptomatic until this point. In addition, the CTPA demonstrated a lateral breech at the left T10 pedicle screw level, with the screw tip in close anatomical proximity to the aortic wall, though no evidence of intraluminal penetration was observed. A multidisciplinary team convened and determined that cardiac management should be prioritized due to the significant hemodynamic impact of the ASD, with the malpositioned screw to be monitored and removed in a subsequent staged procedure. The ASD was successfully repaired via a surgical closure technique, with uncomplicated recovery and normalization of cardiac function. Following cardiac repair, a repeat computed tomography (CT) scan was performed to precisely delineate the position of the left T10 pedicle screw relative to the aorta. Angiographic imaging and intravascular ultrasound (IVUS) confirmed the absence of intra-luminal extension of the screw tip into the aortic lumen. A transesophageal echocardiogram (TEE) was additionally performed, which excluded any extra-luminal contact between the screw tip and the aortic wall. Two years after the initial scoliosis correction, a decision was made to proceed with removal of the spinal instrumentation. The midline surgical scar was reopened, and the spine was exposed across the T3–T12 previously fused segments. A solid


A 13-year-old girl was found to have a little bit of protein in her urine during a school health check. She was born very early, at 23 weeks, and was tiny—only 630 grams, like a baby at that stage. She had some breathing problems and eye issues as a baby, but grew up normally. Her blood pressure is normal, and her urine test showed a small amount of protein. Her kidneys were checked, and they were in stage 2 of kidney disease. Her uric acid level was high, which is not normal—her mom and her 16-year-old brother also have high uric acid. A small test on her kidneys showed a pattern that matches a condition called FSGS. After 3 years of medicine to help her kidneys, the protein in her urine went down, but her kidney disease stayed at stage 2. Doctors think her small size at birth was the first problem, and high uric acid later was the second problem that may have made her kidney disease worse.


A 13-year-old girl was referred to the hospital after a school urine test found mild proteinuria. She was born very prematurely at 23 weeks of pregnancy, weighing only 630 grams — very low for her age. She had some breathing problems as a baby and needed oxygen for a year, but she grew up normally. She has no other major health issues.

At checkup, her urine test showed grade (2+) proteinuria, and her blood test showed a serum creatinine level of 1.02 mg/dL, which led to a diagnosis of stage 2 chronic kidney disease (CKD). Her uric acid level was 7 mg/dL, which is higher than normal (normal is less than 4.6 mg/dL), meaning she had hyperuricemia. Both her mother and her 16-year-old brother also have high uric acid levels.

A kidney biopsy showed signs of a condition called FSGS, where parts of the kidney’s filtering units are damaged. The kidney tissue was also showing some scarring and enlarged filtering areas. Tests for common antibodies were negative, supporting this diagnosis.

She has been treated with an angiotensin receptor blocker (ARB) for three years, and her proteinuria has improved. However, her kidney function hasn’t fully recovered — her creatinine level is now 1.07 mg/dL, and she still has stage 2 CKD. Doctors believe her early low birth weight was the first factor that may have damaged her kidneys, and her high uric acid levels (the second factor) may have worsened the damage. This suggests that both factors played a role in the development of her kidney disease.


{
  "proficient_health_literacy": "A 13-year-old female was referred to our hospital due to mild proteinuria identified during a school-based urinary screening. No prior history of urinary abnormalities existed. She was born at 23 weeks and 6 days of gestation, secondary to maternal fever, with a very low birth weight (LBW) of 630 g, corresponding to the size expected at 23 weeks of gestation. She developed chronic lung disease and retinopathy of prematurity, requiring supplemental oxygen therapy until age 1 year; however, her postnatal growth and neurodevelopmental trajectory normalized by that time. Beyond retinopathy of prematurity, she had no significant comorbidities and remained generally healthy throughout childhood.\n\nPhysical examination revealed a height of 154 cm, weight of 50 kg, body mass index (BMI) of 21.1, and blood pressure of 115/73 mmHg. Dipstick urinalysis demonstrated grade (2+) proteinuria. Her serum creatinine level was 1.02 mg/dL, leading to a diagnosis of stage 2 chronic kidney disease (CKD) using age- and sex-matched reference values for Japanese children aged 12–15 years. Her serum uric acid level was 7 mg/dL, which exceeds the normal range of <4.6 mg/dL for female children aged 12–14 years, confirming hyperuricemia. Both her mother and her 16-year-old brother also exhibit hyperuricemia, suggesting a possible familial predisposition.\n\nPercutaneous renal biopsy revealed segmental glomerulosclerosis in one of eight glomeruli, characterized by sclerosis with adhesion to the Bowman’s capsule (indicated by black arrow), and partial focal interstitial fibrosis (indicated by white arrow). The mean glomerular diameter measured 348.23 μm, significantly larger than the normal glomerular diameter of 168 ± 12 μm, indicating glomerular hypertrophy—a known pathological feature in focal segmental glomerulosclerosis (FSGS). Immunofluorescence staining for IgG, IgA, IgM, C3, C1q, and C4 was negative, excluding immune-mediated glomerulonephritis and supporting a diagnosis of native FSGS, specifically non-immune, likely of the


A 17-year-old girl was taking two medicines for mental illness — lithium and paliperidone — because she had mood swings and heard voices. After a few weeks, she started feeling dizzy, slow, and had a slow heart rate. Her doctor found that her thyroid was not working right and her heart was beating too slowly. These problems went away completely after she stopped taking both medicines. Her heart rate and thyroid levels returned to normal in about 20 days. The doctor thinks the medicines caused these issues, not something else. She now takes a different medicine for her mental health and doesn’t need a pacemaker because her heart fixed itself.


A 17-year-old Han Chinese girl developed symptoms like dizziness, sluggishness, and chest tightness while being treated with lithium and paliperidone for bipolar disorder with hallucinations. She had been diagnosed with bipolar I disorder and was started on these medications during a prior hospitalization. Two months later, her paliperidone dose was reduced, but one week before her visit, her symptoms worsened. Her heart rate was low at 41 beats per minute, and an ECG showed sinus bradycardia and sinus arrest. Blood tests revealed elevated thyroid-stimulating hormone and low thyroid hormone levels, indicating hypothyroidism. Although the symptoms were mild, they were linked to her medication use. The doctors believed the combination of lithium and paliperidone caused these issues. After stopping both medications, her thyroid function and heart rhythm returned to normal within 20 days. She did not need a pacemaker because her heart rhythm improved on its own. She was switched to olanzapine for her mental health condition. The timing of her symptoms and recovery supports the idea that the medications were responsible, not an underlying heart or thyroid disease.


{
    "proficient_health_literacy": "A 17-year-old Han Chinese female presented to the psychiatric outpatient clinic with a one-week history of dizziness, lethargy, and impaired school attendance. Her psychiatric history included a prior hospitalization three months earlier for bipolar disorder with psychotic features, specifically auditory hallucinations, meeting DSM-5 criteria for bipolar I disorder based on a documented manic episode and prior major depressive episodes. During admission, she was initiated on lithium carbonate 500 mg twice daily and paliperidone 9 mg (equivalent to 450 mg chlorpromazine) once daily. Two months later, the paliperidone dose was reduced to 6 mg (equivalent to 300 mg chlorpromazine) once daily. One week prior to her outpatient visit, she developed worsening dizziness, chest tightness, and generalized sluggishness. She reported no personal or family history of cardiac or thyroid disease, no smoking, alcohol use, or illicit drug use; however, these reports were self-identified and not corroborated by clinical documentation. Pre-treatment, she had no known history of thyroid dysfunction or bradycardia.\n\nOn physical examination, her heart rate was 41 beats per minute, consistent with sinus bradycardia, and blood pressure was 95/57 mmHg. Electrocardiography revealed sinus bradycardia and sinus arrest. Serum electrolytes (calcium, potassium) and myocardial enzymes were within normal limits. Thyroid function tests demonstrated an elevated thyroid-stimulating hormone (TSH) of 9.08 mIU/L (reference range: 0.51–4.94 mIU/L), a decreased total thyroxine (TT4) of 45.05 nmol/L (reference range: 58.1–140.6 nmol/L), and a reduced free thyroxine (FT4) of 10.94 pmol/L (reference range: 11.5–22.7 pmol/L), indicating subclinical hypothyroidism without overt clinical manifestations. The patient and her guardian denied any family or personal history of cardiac or thyroid pathology, and no other medications known to induce conduction delays were identified. Although serum lithium levels were not measured due to assay unavailability, her serum paliperidone concentration was within the therapeutic range.\n\nThe clinical presentation—sympt


A 56-year-old woman had been bleeding from her intestines for years, causing fatigue and dizziness. She had small blue bumps on her skin since childhood that grew over time. The bleeding got worse and led to a serious blood problem where blood clots formed all over her body. Tests showed her blood was very low in red cells and had too many clotting markers. She was treated with a procedure called argon plasma coagulation during a special camera check of her intestines, and also took a medicine called sirolimus. After about 8 weeks, her blood levels improved and she stopped bleeding. One year later, she was doing well, her blood counts were stable, and she had not had any more bleeding.


A 56-year-old woman was admitted to the hospital with a 3-year history of fatigue and dizziness, which had worsened over the past 10 days with severe bleeding (melena). She had been hospitalized multiple times before for similar symptoms and had a history of many small, blue growths (venous hemangiomas) since childhood. These growths grew larger and more numerous over time. Tests showed she had severe anemia and a condition called disseminated intravascular coagulation (DIC), where blood clots form throughout the body and then break down, leading to bleeding and low blood clotting. Despite treatment, her hemoglobin levels remained very low, between 39 and 61 g/L, and she required many blood transfusions each year.

No clear source of bleeding was found during endoscopy or colonoscopy. Skin ultrasounds confirmed the blue hemangiomas on her skin. Blood tests showed abnormal clotting times and very low fibrinogen, along with high levels of substances that indicate active clot breakdown.

The doctors diagnosed her with blue rubber bleb nevus syndrome (BRBNS), a rare condition that causes multiple hemangiomas and can lead to bleeding in the intestines. Treatment included argon plasma coagulation (a procedure done during endoscopy to stop bleeding) and the medication sirolimus. After about 8 weeks of treatment, her hemoglobin improved to 100 g/L. At a 12-month follow-up, she was doing well with stable hemoglobin at 102 g/L and no further bleeding.


{
    "proficient_health_literacy": "A 56-year-old female presented with massive intestinal hemorrhage, characterized by a progressive and persistent bleeding course over three years, with acute exacerbation over the past 10 days manifesting as melena. The patient had a longstanding history of chronic constipation and multiple venous hemangiomas since childhood, which demonstrated progressive increase in both number and size with aging. No familial history of hemangiomas or related vascular disorders was identified. Physical examination revealed significant anemia and multiple cutaneous blue hemangiomas protruding from the skin surface, confirmed by skin ultrasound as vascular malformations. Laboratory findings demonstrated severe hematological abnormalities: white blood cell count of 1.78 × 10¹²/L (normal: 3.80–5.10 × 10¹²/L), hemoglobin of 39 g/L (normal: 115–150 g/L), platelet count of 71 × 10⁹/L (normal: 125–350 × 10⁹/L), and positive fecal occult blood. Coagulation profile revealed marked dysregulation: prothrombin time of 17.7 seconds (normal: 9.5–15.0 sec), activated partial thromboplastin time of 55.8 seconds (normal: 20.0–40.0 sec), prothrombin time-international normalized ratio of 1.65 (normal: 0.80–1.50), fibrinogen level of 0.349 g/L (normal: 1.800–4.000 g/L), D-dimer >10,000 ng/mL (normal: 0–500 µg/mL), tissue plasminogen activator-inhibitor 1 complex of 14.10 ng/mL (normal: 0.00–10.50 ng/mL), and plasmin-α2 cellulase inhibitor complex of 12.23 µg/mL (normal: 0.00–0.80 µg/mL), consistent with a fibrinolytic-type disseminated intravascular coagulation (DIC). Imaging studies, including abdominal computed tomography and digital subtraction angiography with mesenteric arteriography, failed to identify any definitive source


A 32-year-old woman had a cough that got worse and started spitting out a lot of blood. The blood was so big it blocked her airway and she almost died. Doctors couldn’t clear the blockage with normal methods, so they used a thin tube (bronchoscope) to go inside her airway and used a medicine called urokinase to break up the blood clots. The clots were removed, and the airway opened up. After that, she was able to stop using the life-support machine, her breathing tube was removed, and she was taken off the ventilator. Now she’s stable. X-rays and scans show her lungs are getting better.


A 32-year-old woman was admitted to the hospital with a cough that had lasted for 7 days and had suddenly worsened with large amounts of blood in her cough (hemoptysis) over the previous 9 hours. She had a history of Hashimoto thyroiditis, but it was not well managed. Chest CT scans showed pneumonia with bleeding in the lungs and thick mucus plugs blocking the airways, especially in the right lung. Her condition quickly got worse, with a large amount of fresh blood and a blood clot in her airway. Her oxygen levels were very low, and her breathing was difficult. Because standard methods to clear the airway were not working, doctors decided to use a procedure called fiberoptic bronchoscopy, combined with a medication called urokinase, to remove the large blood clots. This successfully cleared the blockage in her airway. After treatment, she was able to be taken off the life-support machine (extracorporeal membrane oxygenation), had her breathing tube removed, and was safely taken off the ventilator. Her current condition is stable, and follow-up chest X-rays and CT scans show improvement compared to when she first arrived at the hospital.


{
    "proficient_health_literacy": "A 32-year-old female was admitted to the hospital on May 17, 2023, at 15:51 with a chief complaint of a cough lasting seven days that had progressively worsened over the preceding nine hours, presenting with hemoptysis of 100 mL of blood. She had a history of Hashimoto thyroiditis, which was not systematically managed. Initial chest computed tomography (CT) revealed bilateral pneumonia with alveolar hemorrhage, prompting a recommendation for reevaluation post-treatment. Additionally, multiple bronchial mucus plugs were identified in the right main bronchus and in the middle and lower lobes of the right lung, suggesting obstructive airway pathology due to mucopurulent secretions and impaired clearance mechanisms. During the same day's afternoon, she experienced a recurrence of hemoptysis, characterized by a large volume of fresh blood mixed with a small amount of blood clot, indicating active intrapulmonary hemorrhage and potential clot formation within the airway lumen. Physical examination demonstrated a temperature of 36.2 °C, tachycardia (pulse: 128 beats/min), tachypnea (respiration: 25 breaths/min), hypotension (blood pressure: 75/49 mm Hg), and severe hypoxemia (finger-tip oxygen saturation: 50%). Breath sounds were diminished in the right lung, consistent with airway obstruction, while the left lung exhibited prominent moist rales, suggestive of interstitial fluid accumulation or pulmonary edema. Given the severity of airway obstruction and the failure of conventional clearance techniques—including postural drainage and mechanical suction—fiberoptic bronchoscopy was performed in conjunction with urokinase therapy. Urokinase, a serine protease that activates plasminogen to plasmin, was administered to induce fibrinolysis, thereby promoting the dissolution of intrapulmonary blood clots and facilitating their mechanical extraction via bronchoscopic instrumentation. The procedure successfully removed extensive intrapulmonary blood clots, leading to immediate relief of airway obstruction. Subsequent management included weaning from extracorporeal membrane oxygenation (ECMO), successful extubation, and liberation from mechanical ventilation. Post-intervention follow-up imaging, including chest X-ray and high-resolution computed tomography (CT), demonstrated significant improvement in lung parenchymal density and airway pat


A man in his 70s had bleeding in his stomach area and pain for a few days. Doctors found a tumor in his small intestine that had spread to his groin. This rare kind of tumor, called GIST, was already growing in his belly and had moved into a hernia in his groin. The doctors first removed the main tumor and the spread parts, then fixed the hernia with surgery. After that, he took medicine to fight the tumor. Later, they found the tumor had grown inside the hernia, so they removed it completely. The man is still doing well, no pain, no return of the hernia, and can go about his daily life. In the past, very few people had this tumor show up in a groin hernia. All known cases needed both tumor removal and hernia repair. After 5 years, about 6 out of every 10 people with this disease are still alive.


A 71-year-old man came to the hospital with severe abdominal pain and blood in his stool that had lasted for 38 hours. He had no other medical problems or prior surgeries. During the exam, his abdomen was tender, and a mass was found in his small intestine on CT scan, which was causing bleeding. A small mass was also seen in his groin, but it was not noticed at first. The surgery showed a gastrointestinal stromal tumor (GIST) in the jejunum, with spread to other areas of the abdomen. The tumor was removed with a partial resection (R1), and the bowel was reconnected. The patient recovered well and was discharged after 11 days. Pathology confirmed it was a high-risk GIST with fast-growing features. After surgery, he started imatinib chemotherapy for three months. Later, he developed a painful, non-reducible hernia in his right groin, which was confirmed to be a metastasis of the same GIST. The hernia was repaired with surgery, and the tumor was removed along with the hernia sac. The final path report showed the tumor had spread to the groin and was still aggressive. He continued imatinib treatment and has been doing well at his last follow-up in February 2020—still alive and able to work without any signs of recurrence. A review of similar cases shows that GIST presenting as a groin hernia is very rare, and all such cases involved a primary tumor that needed both tumor removal and hernia repair. Long-term survival after diagnosis was about 64.3% at 5 years.


{
    "proficient_health_literacy": "A 71-year-old male presented to the emergency department with a 38-hour history of diffuse abdominal pain and intermittent hematochezia. He denied other gastrointestinal or genitourinary symptoms and had no prior abdominal surgery or significant comorbidities. Physical examination revealed abdominal tenderness with extensive rebound tenderness; however, the groin was not systematically examined due to the absence of specific complaints. Laboratory evaluation demonstrated hypohemoglobinemia (9.6 g/dL). Contrast-enhanced computed tomography (CT) identified lower gastrointestinal bleeding originating from a ruptured mass measuring 5.2 × 4.1 × 3.0 cm³ located in the small intestine, specifically the third jejunal segment (220 cm from the duodenal-jejunal flexure). Concurrently, CT imaging detected a small mass (2.0 × 1.5 × 0.5 cm³) in the right groin, which was not explicitly noted in the initial emergent report.\n\nGiven hemodynamic instability, the patient underwent emergent laparotomy. Intraoperative findings revealed a primary gastrointestinal stromal tumor (GIST) arising from the jejunal wall, with disseminated, multi-focal tumor seeding throughout the peritoneal cavity. A palliative resection was performed, encompassing the primary tumor and all seeding lesions exceeding 2 mm in size, resulting in an R1 resection (resection with microscopic residual disease), followed by side-to-side jejunal anastomosis. The patient was discharged on post-operative day 11 without complications.\n\nHistopathological analysis of the primary tumor demonstrated spindle cell morphology, with a high mitotic rate (25/50 high-power fields, HPF) and significant areas of tumor necrosis (see Additional file: Fig. S1). Immunohistochemical (IHC) staining showed strong positivity for CD117, DOG-1, and SDHB; mild positivity for actin and desmin; and negativity for CD34 and S-100. The Ki-67 proliferation index was 20%. Molecular profiling revealed a mutation rate of 18.22% in the c-KIT gene, specifically a duplication at exons 9 (A502_T503dup), classifying the tumor as high-risk jejunal GIST.\n\nPostoperative management included imatinib therapy at a dose


A 53-year-old woman who had two back surgeries before had a sudden worsening of her back pain, causing her legs to go weak and her bladder to stop working. This is a serious problem called cauda equina syndrome. Her blood tests showed signs of infection, and a scan found a pus-filled bump pressing on her spinal nerves from L4 to S1. The doctors drained the pus and found a small piece of old surgical cotton that had been left behind — it was causing the infection. The cotton was removed and the infection cleared after 2 months of antibiotics. The antibiotics worked, but her leg weakness only got better a little, not fully.


A 53-year-old woman with a history of two back surgeries at the L4-S1 levels — one 11 years ago and another 2 years ago — developed a sudden, serious condition called cauda equina syndrome. This caused weakness in her legs (paraparesis) and loss of bladder control. She had mild signs of infection in her blood (elevated white blood cell count and C-reactive protein), which matched findings on MRI showing a large abscess in the spine from L4 to S1. The abscess was drained during surgery, and a small, hard lump found inside it was identified as a retained piece of surgical cotton (a known cause of long-term infection). This cottonoid was removed, and the infection was treated with ciprofloxacin for two months. The infection cleared, but her leg weakness only improved partially. The tissue around the cottonoid showed chronic inflammation and scar tissue, and no signs of infection returned after one year.


{
    "proficient_health_literacy": "A 53-year-old female with a longstanding history of low back pain underwent two prior spinal surgical interventions: an L5-S1 discectomy performed 11 years earlier and an L4-L5 decompressive laminectomy 2 years prior. Over a period of several weeks, she presented with an acute cauda equina syndrome, clinically manifesting as paraparesis and acute urinary incontinence. Physical examination revealed mild tenderness in the lower back region. Laboratory evaluation demonstrated a mildly elevated white blood cell count (12,600/mm³) and a significantly increased C-reactive protein level, consistent with acute inflammation, without evidence of urinary tract infection. Plain radiographic imaging confirmed the anatomical defects attributable to prior laminectomies at the L4-L5 and L5-S1 levels. Magnetic resonance imaging (MRI) revealed an oblong posterior epidural lesion extending from the L4 to S1 levels, which was hypointense on T1-weighted sequences and hyperintense on T2-weighted sequences, exhibiting ring enhancement after gadolinium administration—findings consistent with a post-infectious epidural abscess. Given the clinical and imaging features, a decompressive laminectomy was performed to relieve spinal cord compression. Intraoperatively, a well-encapsulated posterior epidural abscess was identified and drained. Histopathological analysis of the abscess wall revealed a granulomatous lesion, subsequently identified as a retained surgical cottonoid, located at the antero-inferior aspect of the abscess wall at the S1 level. This lesion was completely excised, along with adjacent marginal fibrotic capsular tissue. Microbiological culture of the thick, fibrotic abscess capsule yielded Klebsiella oxytoca, a Gram-negative bacillus commonly associated with nosocomial and postoperative infections. The patient was treated with intravenous ciprofloxacin for a duration of two months, after which the infection was fully resolved. However, despite successful eradication of the infectious process, the motor deficit associated with the cauda equina syndrome only partially recovered. Postoperative histopathology confirmed the presence of a textiloma, a fibrogranulomatous reaction to foreign body material, with chronic inflammation and extensive fibrosis surrounding the retained cottonoid. At one-year follow-up, no recurrence of infection was observed, indicating complete resolution of the infectious component and stable surgical outcome, though neuro


A 72-year-old man had cancer in his bile duct, so doctors removed part of his pancreas and small intestine (pancreaticoduodenectomy). After the surgery, his bile duct got blocked in one part, which made it hard for bile to flow. To fix this, doctors used a special test (DIC-CT) to see exactly where the bile duct was and how it was blocked. They found the blockage was in a small part of the bile duct, and the small intestine was raised up, which made it hard to connect. Using a tiny needle and CT guidance, they pierced the bile duct and checked it with a small camera. They pushed a thin wire through the needle and felt the wall of the bile duct vibrate — this showed the needle went right into the blocked area. When they did this, they saw the raised part of the small intestine was squeezed a little, which confirmed the needle was in the right spot. Then they placed a small tube (8.5-Fr pigtail catheter) into the raised small intestine to help bile flow. After that, they put in a metal stent to keep the tube open. The patient recovered well, went back to regular visits, and had no problems with the stent even after 6 months.


A 72-year-old Japanese man had middle bile duct cancer and underwent surgery called a pancreaticoduodenectomy to remove the tumor. During the surgery, a complication occurred: a blockage in the posterior segment of the bile duct, which is a part of the bile duct system. To figure out how the bile duct and the elevated jejunum (a part of the small intestine) were positioned, doctors performed a drip infusion cholecystocholangiography-computed tomography (DIC-CT) test. This test showed that the bile duct was isolated and that there was no tissue or organ between it and the elevated jejunum, making it safe to connect them. Using CT guidance, the doctors made a small puncture in the bile duct and used an endoscope to see the connection site. They inserted a guide wire through a needle and felt vibrations in the bile duct wall, which confirmed the needle had reached the correct spot. When the wire was placed, they saw that the elevated jejunum was partially compressed, which helped confirm the puncture was successful. They then successfully placed an 8.5-Fr pigtail catheter into the elevated jejunum. After that, all drains were removed, and a metal stent was placed directly into the bile duct to keep it open. The patient recovered well and now visits the clinic as an outpatient. Six months later, the stent is still open and working without any problems.


{
    "proficient_health_literacy": "A 72-year-old Japanese male with no significant prior medical history was referred for evaluation of jaundice and impaired hepatic function identified during a routine health screening. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) revealed stenosis in the middle bile duct, and biliary abrasive cytology confirmed a Class V adenocarcinoma, consistent with malignant obstruction. Imaging demonstrated a low bifurcation in the posterior segmental bile duct branch, which informed the surgical planning for pancreaticoduodenectomy due to middle bile duct cancer. Postoperatively, the patient remained asymptomatic with only mild postoperative inflammation, and was discharged on postoperative day 22. However, on postoperative day 30, blood work revealed elevated inflammatory markers, prompting further investigation. Contrast-enhanced computed tomography (CT) showed abscess formation adjacent to the hepaticojejunal anastomosis site and posterior segmental bile duct dilatation, suggesting bile leak or ischemic injury. Initial management included percutaneous transhepatic biliary drainage (PTBD), which demonstrated contrast filling only in the posterior segmental branch, with no evidence of bile leakage into the elevated jejunum. Subsequent endoscopic contrast radiography from the hepaticojejunal anastomosis site revealed visualization of only the anterior segmental branch and left branch, confirming the anatomical lesion was localized to the low bifurcation of the posterior segmental bile duct. Bile output via PTBD averaged approximately 250 ml/day over consecutive days. To assess the spatial relationship between the posterior segmental bile duct and the elevated jejunum, a drip infusion cholecystocholangiography-computed tomography (DIC-CT) test was performed. This imaging modality demonstrated contrast reflux into the elevated jejunum from the anterior segmental and left branches, while the posterior segmental branch was dorsally visualized with a poorly defined anatomical relationship to the jejunum. Notably, no intervening abdominal organs were identified between the bile duct and the elevated jejunum, supporting the feasibility of percutaneous transhepatic internal biliary drainage of the isolated posterior segmental bile duct into the elevated jejunum. Under computed tomography (CT) guidance, a precise puncture was made into the posterior segmental bile duct, followed by endoscopic visualization of the hepaticojejunal anastomosis site. A guide


A 19-year-old young man had surgery on his nose and nose bones. He was healthy before surgery, no problems with his voice or breathing, and no other medical issues. The doctors thought his airway was normal and safely able to handle anesthesia. During the surgery, they put a breathing tube in easily without any trouble. After the surgery, he started to have a hoarse voice, which lasted for several days. On the sixth day, doctors saw that one of the small bones in his voice box (the arytenoid cartilage) had slipped out of place. They fixed it with a small surgery under anesthesia, and his voice slowly got better over six weeks. He had no other symptoms or problems.


A 19-year-old Caucasian male had a routine surgery for nose and nasal bone correction (septorhinoplasty). He had no known medical problems, such as diabetes, lung issues, or weakened joints, and was considered healthy before surgery (ASA Class I). His airway was normal, and intubation (inserting a tube into the windpipe) went smoothly without complications. The patient did not cough during the procedure, and the surgery lasted four hours with no issues. After surgery, he developed moderate hoarseness, which lasted for several days. On the sixth day, a doctor found that the left arytenoid cartilage — a small bone in the voice box — had moved out of place. This caused the hoarseness. The cartilage was gently repositioned under anesthesia using a bronchoscope and steroid injection. Over the next six weeks, his voice improved. He had no other symptoms and was discharged on the second day. This case shows that even in healthy young patients, a rare condition like arytenoid cartilage dislocation can occur after surgery, though it is usually treatable.


{
    "proficient_health_literacy": "A 19-year-old Caucasian male underwent septorhinoplasty under general anesthesia. His medical history was unremarkable, with no prior laryngeal pathology, diabetes mellitus, chronic renal failure, chronic corticosteroid use, laryngeal malacia, or acromegaly—all of which are known risk factors for cricoarytenoid joint instability. Preoperative evaluation, including physical examination and laboratory workup, was normal, consistent with an American Society of Anesthesiologists (ASA) physical status classification of I. Airway assessment revealed a class 2 airway, with normal Mallampati score and other standard airway parameters. Anesthesia was induced with thiopental (8 mg.kg⁻¹), rocuronium (0.6 mg.kg⁻¹), and remifentanyl (0.5 mcg.kg⁻¹), achieving complete muscle relaxation prior to endotracheal intubation. Using a Macintosh 4 laryngoscope blade, direct laryngoscopy demonstrated a short epiglottis and a glottis grade II according to the Cormack-Lahene classification, indicating a relatively straightforward visualization. A 8.0-mm endotracheal tube was successfully inserted on the first attempt without resistance, and was secured at the mid-trachea. The patient did not experience coughing or other reflexive responses during intubation. Intraoperative anesthesia was maintained with a mixture of nitrous oxide, oxygen, isoflurane, remifentanyl (0.25 mcg.kg⁻¹.min⁻¹), and rocuronium, with no complications during the four-hour surgical procedure. Postoperatively, the endotracheal tube was removed without incident, and the patient did not exhibit severe coughing or vomiting. On postoperative day 1, he reported moderate hoarseness, which persisted through day 6. No other symptoms were present. On day 6, fiberoptic laryngoscopy performed by an otorhinolaryngologist revealed anteromedial dislocation of the left arytenoid cartilage—a rare but clinically significant finding. This dislocation is likely due to a transient biomechanical disruption during the surgical maneuver or anesthesia-induced relaxation of the laryngeal musculature, possibly exacerbated by the inherent structural variability of the arytenoid cartilage in young individuals, though no predisposing conditions were identified


A young, healthy woman found a lump on her small finger that had been growing for months. It got bigger during her pregnancy, almost the size of an olive, and caused pain when her baby grabbed it. First, doctors thought it was a common cyst, but it didn’t go away. Later, tests showed it was a type of cancer called leiomyosarcoma. There was a small bump in her armpit, but doctors said it wasn’t serious. The cancer was caught early and only in her finger. She had surgery to remove the finger (a ray amputation) and the cut was clean with no cancer left behind. After surgery, she had no pain, no new lumps, and her hand worked well. She’s been cancer-free for months and is doing great with physical therapy. Her scar is noticeable but she’s working on it. No signs of cancer have come back.


A 24-year-old woman with no major health problems was diagnosed with a primary leiomyosarcoma in her small finger. The tumor had been growing for months, and its size changed depending on her pregnancy — it sometimes grew as large as an olive. She first visited urgent care, where the mass was thought to be a ganglion cyst, but it wasn't removed. Later, the mass became painful and started bleeding, leading to a biopsy that confirmed it was a low-grade leiomyosarcoma. Imaging showed a suspicious lymph node in her armpit, but doctors believed it was just a normal reaction, not cancer. The cancer was classified as stage 1A, meaning it was localized and early. A second opinion confirmed the diagnosis. After discussion with her medical team, she had a ray amputation of her small finger, removing the tumor at the level of the mid-metacarpal bone. The surgery was successful, with clear margins and no signs of cancer left behind. She also had nerve reinnervation to help preserve hand function. Following surgery, she had regular follow-ups and imaging, all of which showed no signs of cancer. She is now disease-free, with good hand function and no pain or new masses. She continues to do well and is recovering well with physical therapy.


{
    "proficient_health_literacy": "A 24-year-old right-hand dominant Hispanic female presented to an urgent care clinic in October 2021 with a palpable mass on the ulnar aspect of the proximal interphalangeal (PIP) joint of her right small finger, which had been present for several months. She reported cyclical changes in mass size, with growth during pregnancy—reaching up to the size of an olive—and worsening pain associated with her newborn's frequent grasping of the finger. Initial attempts at aspiration were unsuccessful, and the mass was initially diagnosed as a ganglion cyst. Subsequent evaluation by a local hand surgeon was planned but never executed. In March 2022, she returned with progressive pain and an open, bleeding wound at the original site, prompting imaging. Plain radiographs revealed a soft tissue mass near the PIP joint with incidental punctate calcifications. An excisional biopsy was performed on March 15, 2022, and reviewed by two independent pathologists, confirming a diagnosis of low-grade leiomyosarcoma of the finger. Immunohistochemical staining and histopathological analysis supported this diagnosis, showing characteristic expression of smooth muscle markers (e.g., desmin, caldesmon, SMA) and absence of features consistent with benign fibroblastic or epithelial tumors. A PET/CT scan performed in early April 2022 identified a suspicious right axillary lymph node, which the treating oncologist and general surgeon interpreted as reactive and benign, consistent with inflammatory or post-traumatic changes. The clinical and pathologic staging aligns with AJCC stage IIA, indicating a localized tumor with no regional lymph node metastasis. The primary lesion was also visible on PET/CT. A second opinion from a general surgeon reinforced the benign nature of the lymphadenopathy. In early May 2022, the tumor board at the treating institution recommended ray amputation as the most appropriate oncologic intervention given the tumor's location, histologic grade, and lack of evidence of systemic spread. Concurrent laboratory studies were unremarkable, with no signs of infection or systemic inflammation. On the same day, a new mass was noted distal to the original lesion on the small finger, with imaging consistent with a potential second focus of leiomyosarcoma. On June 15, 2022, the patient underwent successful right-hand minor finger ray amputation, with the small finger amputated


A 64-year-old woman who had cancer in her ovaries and was already treated before, now has pain, belly swelling, and trouble moving food through her gut. The cancer spread to her belly lining and intestines. After first treatment, she got better and had no cancer signs for a while. Then, the cancer came back. She tried a new drug combo — trabectedin and PLD — which worked well, and after a few cycles, she stayed in good shape. Even when she only took trabectedin alone, she kept getting better and stayed healthy for over two years. She had no major side effects and could do everyday things. This shows that trabectedin, even by itself, can help control this cancer for a long time.


A 64-year-old woman who had recurrent ovarian cancer after menopause was treated with a second-line chemotherapy combination of trabectedin and PLD, followed by trabectedin alone. She had symptoms like abdominal pain, bloating, and changes in bowel movement, and imaging showed widespread cancer in her abdomen and pelvis. After initial treatment with chemotherapy and surgery, her cancer went into complete remission. However, it returned seven months later, prompting a switch to trabectedin and PLD, which worked well — her cancer markers dropped significantly. Although she had side effects like low blood counts, the treatment was well tolerated. After the combination was stopped due to toxicity, she continued with trabectedin alone, which kept her cancer under control for over two years. Even after a later recurrence, she responded to further treatment with bevacizumab, which she continues to take to maintain her response. The case shows that trabectedin, especially when used alone, can be effective and well tolerated in managing recurrent ovarian cancer over a long period.


{
    "proficient_health_literacy": "A 64-year-old Caucasian postmenopausal woman presented with persistent pain, abdominal distension, and altered intestinal transit, consistent with advanced gastrointestinal malignancy. Imaging via thoracic and abdominopelvic computed tomography (CT) revealed extensive peritoneal carcinomatosis, massive ascites, involvement of the greater omentum, diffuse mesenteric spread involving the small intestine, diffuse parietal peritoneal implants, and suspicious lesions at the base of the Douglas pouch with probable ovarian surface involvement despite normal ovarian size. Plasma CA-125 levels were 1,110.9 U/mL, with other tumor markers within normal limits. Omental biopsy confirmed high-grade serous carcinoma (HGSC), demonstrating positive immunohistochemical expression for WT-1, p53, and CK-7, and negative expression for CK20 and TTF-1, supporting a gynecological origin (tube-ovarian-peritoneal). The diagnosis was classified as primary peritoneal carcinoma of gynecological origin, stage IIIC, with unresectable disease due to extensive mesenteric infiltration.\n\nNeoadjuvant chemotherapy was initiated with intravenous paclitaxel 175 mg/m² and intravenous carboplatin AUC 6 administered every 21 days for three cycles. Follow-up CT imaging demonstrated a significant partial response, with CA-125 levels dropping to 65 U/mL (a 95% reduction from baseline). Subsequently, surgical cytoreduction was performed, achieving optimal tumor resection, and an intraperitoneal (i.p.) catheter was placed for future delivery of i.p. chemotherapy. Pathological evaluation of resected specimens confirmed high-grade serous carcinoma.\n\nAdjuvant intraperitoneal chemotherapy was delivered over four cycles: i.v. paclitaxel 175 mg/m² on day 1, i.p. cisplatin 75 mg/m² on day 2, and i.p. paclitaxel 60 mg/m² on day 8. The patient achieved a complete clinical response, although treatment-related toxicity included grade-2 asthenia and grade-3 neutropenia, necessitating dose delay and granulocyte-colony stimulating factor (G-CSF) support.\n\nSeven months after completion of platinum-based therapy, follow-up CT imaging revealed mediastinal


A 36-year-old woman who is overweight fell down the stairs and broke her right elbow. She had a break in the middle of her radius bone, a break near the top of the radius with a 15-degree twist, and her elbow popped out of place. First, the doctors fixed the popped-out elbow. Then they used surgery to fix the two breaks in the radius bone and put the elbow back in place. They made sure the elbow stayed stable and the soft parts around it were reattached. She wore a splint for 6 weeks and started moving her arm early, first with bending and straightening, then with turning her hand. After 6 weeks, she could only bend a little and turn her hand a little. By 3 months, she could bend and straighten much better and turn her hand more. By 5 months, she could move her arm almost normally again, and her thumb worked well. She was able to go back to work as a funeral director after 5 months.


A 36-year-old woman with obesity suffered a fall down the stairs, which caused a break in her right radial bone (radial diaphyseal fracture), a break in the neck of the radius with about 15° angulation, and a dislocation of her elbow (posterolateral elbow dislocation). She was admitted for treatment. First, the doctors reduced the elbow dislocation and stabilized the broken radius bones using surgery. They also repaired the damaged structures around the elbow. A CT scan was done to check for damage to the elbow’s stabilizing parts, and no coronoid bone injury was found. The radial neck fracture did not fully heal initially, so a second surgery was performed using a specific approach between two muscles to fix the fracture and reattach the elbow’s posterior structures. The radial nerve was protected during surgery by keeping the elbow in a pronated position. After surgery, she wore a splint for 6 weeks and began physical therapy early, starting with gentle movement. By 3 months, she had regained most of her elbow motion, though she still had some numbness in her radial nerve area. By 5 months, her range of motion improved significantly, including full recovery of thumb movement, and she was able to return to her job as a funeral director.


{
    "proficient_health_literacy": "A 36-year-old female with obesity (BMI 34) was admitted following a low-energy fall down stairs, resulting in indirect trauma to the right elbow. Clinical examination revealed upper limb trauma without distal neurovascular compromise. Radiographic imaging demonstrated a 2R2A2 radial diaphyseal fracture and a 2R1A2 radial neck fracture with approximately 15° of angulation, along with a posterolateral humeroulnar dislocation. The initial intervention was emergency reduction of the humeroulnar dislocation, during which ligamentous stability was compromised due to the concomitant diaphyseal fracture. The patient was immobilized in a brachio-antebrachial-palmar (BABP) splint, and a computed tomography (CT) scan was performed to evaluate the integrity of the elbow's stabilizing ligamentous and bony structures, with no evidence of coronoid involvement identified.\n\nOsteosynthesis of the radial diaphysis was performed under regional anesthesia using a Synthes compression plate with a working length of two screw holes and a lever arm spanning six contiguous cortices on both sides, providing biomechanical stability through cortical interlocking. Post-reduction elbow assessment demonstrated no recurrent dislocation up to −40° of extension, though persistent displacement of the radial neck fracture remained.\n\nA Cadenat approach was employed to access the radial neck fracture, performed between the ulnar extensor and anconeus muscle, allowing direct visualization of the metaphyseal fragment shift while preserving the motor branch of the radial nerve by maintaining elbow pronation. The fracture was stabilized using an anatomical radial head plate (Trilock Radial Head Plates, Medartis), and the posterolateral elbow structures were reattached. Given the achieved joint stability, no additional medial stabilization procedures were indicated.\n\nPostoperative immobilization was maintained for 6 weeks in a BABP splint, with early rehabilitation initiated for flexion and extension. Pronation and supination were permitted beginning at the third week. At 6 weeks, range of motion was: flexion-extension 10°/0°/20°; pronation-supination 0°/0°/10°, with a deficit in thumb flexion. At 3 months, motion improved to flexion-extension 0°/40°/120°;


A woman with a tough-to-treat ovarian cancer that kept coming back got sick and lost a lot of weight because of the tumors. Her cancer didn’t show the usual signs that help doctors treat it, and tests found it had low cancer activity, but two small changes in the tumor genes. The doctors tried a new treatment: a drug called pembrolizumab and another called bevacizumab, given every three weeks. After just one round, her cancer marker went down a lot. By the seventh round, it was back to normal. A scan showed the tumors shrunk a lot, and after nine rounds, the cancer was completely gone. She started to get better, gained weight, and her muscles and fat returned. The only side effect was mild joint pain in her hands. No other serious problems happened.


A 42-year-old woman with advanced ovarian clear cell carcinoma (OCCC) had multiple surgeries and chemotherapy treatments, but her cancer returned and became difficult to control. Her tumors spread widely and caused severe weight loss (cachexia) and other symptoms. Tests showed her cancer had low mutation activity, no PD-L1 protein, and two specific gene mutations (ARID1A), which made her a candidate for a new type of treatment. Instead of traditional chemo, she received pembrolizumab and bevacizumab together every three weeks. After just one cycle, her tumor marker CA-125 dropped sharply and returned to normal after seven cycles. CT scans showed a big reduction in tumor size, and she achieved complete remission after nine cycles. Her weight and strength improved significantly, and she recovered from severe wasting. The only side effect was mild joint pain in her hands. No other serious side effects were seen, and she has remained free of cancer since then.


{
    "proficient_health_literacy": "A 42-year-old Asian woman, gravida 0, para 0, initially presented with a suspected ovarian chocolate cyst at Kaiser Hospital in southern California in March 2014, which was pathologically diagnosed as clear cell carcinoma. Following optimal debulking surgery, she was found to have FIGO stage II disease and received adjuvant chemotherapy with paclitaxel and carboplatin for seven cycles. Recurrent disease was detected in January 2016, evidenced by rising serum CA-125 levels and pelvic tumor recurrence, prompting a secondary debulking procedure and subsequent treatment with carboplatin and gemcitabine. Despite this, deep pelvic recurrence near the sigmoid colon, rectum, and bladder emerged in September 2017, progressing despite salvage chemotherapy regimens including liposomal doxorubicin and topotecan. In February 2019, she presented to a medical center in Taiwan for a third debulking surgery involving resection of the sigmoid colon, rectum, and bladder, followed by small bowel bypass, T-colostomy, and bilateral percutaneous nephrostomy. Postoperative tumor recurrence occurred, with two major pelvic and abdominal masses forming shortly thereafter, leading to palliative management due to treatment refractoriness. An experimental immune cell therapy with undefined immunological cells was attempted but was ineffective. She subsequently presented to our institution in April 2019 with elevated serum CA-125 (1236.6 U/mL), a pelvic mass causing vaginal bleeding, and severe cachexia. Comprehensive genomic profiling using FoundationOne CDx, covering over 300 cancer-related genes, revealed a stable microsatellite instability (MSI) status, low tumor mutational burden (TMB), and two somatic mutations in the ARID1A gene, a component of the SWI/SNF chromatin remodeling complex implicated in transcriptional regulation and tumor suppression. Immunohistochemical analysis of tumor tissue demonstrated PD-L1 negativity, indicating absence of programmed death-ligand 1 expression, which is a key immune checkpoint molecule that typically enables tumor immune evasion. Given the absence of PD-L1 expression and the known limitations of immune checkpoint inhibitors in epithelial ovarian cancer (EOC) based on prior clinical trial data, a combination therapy approach was selected with pembrolizumab (200 mg) and bevacizumab (15 mg/kg,


A 15-year-old boy had pain and swelling in his lower back for 4 months. Doctors found a growing lump on his spine, mostly on the left side, using X-rays, MRI, and CT scans. They called it an ABC. To fix it, they first blocked the blood supply to the lump, then removed it completely with a special surgery. They also fused the bones in his lower back to stabilize it. Two years later, he had no pain and the lump didn’t come back. The only small problem was a loose screw on one side, but it wasn’t causing any symptoms.