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Anemia due to blood loss in obscure intestinal bleeding

43 years old patient without any notable pathologies in anamnesis. After two episodes of severe hematochezia the patient underwent EGD, Colonoscopy, digestive system X-rays with contrast medium and capsule endoscopy camera (digestive system micro camera) without any pathological evidences

Chronic Atrial Fibrillation in Patient with Prior Hemoptoic Episodes in Bilateral Bronchiectases

74-year-old female suffers from recurrent episodes of paroxysmal atrial fibrillation (PAF) and has been recommended oral anti-coagulant therapy with warfarin (Coumadin). She has mitral regurgitation, and on the other hand was diagnosed as suffering from congenital bronchiectasis with several episodes of significant bleeding (hemoptysis). Following these hemoptoic episodes she underwent series of diagnostic as well as therapeutic pulmonary intervention (bronchoscopy, angiography, embolization).

Metastatic melanoma stage IIIC

A 58 year-old woman who first presented for evaluation of a bleeding pigmented lesion on the back. An excisional biopsy was performed and revealed a nodular melanoma. A wide excision was performed and no residual melanoma was identified. After a sentinel lymph node biopsy found to be positive, a completion of node dissection was performed and on pathological evaluation, total 6 of 17 lymph nodes contained melanoma.
Staging studies included whole body PET/CT scan and a head CT. FDG uptake by PET was noted in the left axilla only, with no evidence of more distant metastatic disease.

Juvenile Arthritis with Systemic Onset (Stills Disease) – Additional Opinion

60-year-old patient was diagnosed with Still's disease. He was treated with high doses of corticosteroids (methylprednisolone, 110 mg daily). The dose was gradually lowered to 4 mg daily. In the last 2 years he had two exacerbations of the disease which were successfully treated by the increased dose of methylprednisolone. The expert recommends different complementary treatments that can be helpful to reduce pain , other symptoms and inflammation, reduce the dose of the drugs needed to control the disease, and improve quality of life.

Massive Portal and Mesenteric Vein Thrombosis

47-year-old male presented with un-provoked portal and mesenteric vein thrombosis that caused persistent radiating pains of upper abdominal quadrants. The examinations found heterozygous factor II mutation, and family survey for the factor II mutation was recommended. The patient started anticoagulant therapy. In the expert's opinion, the main risk factors for portal vein thrombosis are: Prothrombotic disorder, abdominal inflammation, cirrhosis, cancer, abdominal intervention and abdominal infection.

Infiltrating Duct Carcinoma of Breast – additional opinion

51-year-old female was diagnosed with stage I, Grade I infiltrating duct carcinoma of the breast. Estrogen receptors were highly positive and Progesterone receptors negative. Based on these findings the expert advises that she receive adjuvant radiotherapy and hormonotherapy. The adjuvant hormonotherapy consist of initial treatment by Tamoxifen for 2 years, thereafter switched to an Aromatase Inhibitor. The expert also informs the patient about potential side effects of Tamoxifen treatment, which are not frequent and generally mild.

Multiple Myeloma (MM) and Cardiomyopathy

51-year-old-male, complained of low back pain and has been diagnosed as having multiple myeloma (MM), light chain disease of the lambda type. His past medical history is remarkable for a cardiac disease. The expert believes it is cardiomyopathy, which can be amyloidotic (related to the MM) or hypertensive-atherosclerotic, or combined. The patient received anti-MM induction type of treatment (VTD combination), followed by high-dose cyclophosphamide (HDC) and autologous stem cell transplantation. The patient's low platelet count is of concern.

Symptomatic Pancytopenia

74-year-old male has suffered over six months from pancytopenia. The main problem has been the symptomatic anemia, which required blood transfusions. Bone marrow aspiration revealed some myelodysplasia, and immune therapy has been prescribed. The expert suggests possible differential diagnosis of pancytopenia and recommends to establish a definite diagnosis before discussing treatment.

MDS – Myelodysplastic Syndrome

74-year-old male with gradual pan-cytopenia with predominant thrombocytopenia underwent a bone marrow biopsy that confirmed the diagnosis of Myelodysplastic syndrome (MDS). He is currently in good general health except for slowly progressive weakness and being constantly tired. In the expert's opinion, there is no indication for therapy at this time, since the counts are satisfactory for every-day living. Nevertheless, the treating options are erythopoietin injections, lenalidomide, Vidaza or Dacogen therapy, or stem cell transplantation.

Symptomatic Pancytopenia- Additional opinion

74-year-old male suffers from pancytopenia and symptomatic anemia. Bone marrow aspiration revealed some myelodysplasia, and the patient started immune therapy. He continues to require repeated blood transfusions. The expert recommends to complete the diagnostic workup. If no other disease is diagnosed than it can be assumed that the patient carries the diagnosis of MDS hypoplastic type.

Age Related Macular Degeneration – additional opinion

62-year-old male complained of decreased visual acuity in his right eye for 1 week. His past ocular history was relevant for an episode of central serous choroidopathy. Upon examination there was a large subretinal hemorrhage in the macular area , with a visible choroidal neovascularization. Intravitreal Bevacizumab (Avastin) was injected. One week following treatment, there was still macular bleeding and no improvement in visual acuity. Therefore, a vitrectomy was performed. There was impressive resolution of the subretinal hemorrhage but still some intraretinal fluids.

Myelodysplastic syndrome (MDS), with kariotype del(11)q(11)

A 74 year-old male, that was diagnosed as suffering from myelodysplastic syndrome (MDS) with kariotype del(11)q(11) by a bone marrow biopsy, following a gradual pancytopenia. The patient complains about slowly progressive weakness and being constantly tired.He was offered chemotherapy, but he declined this treatment because of fear that it would worsen his already severe weakness.

Adeno Carcinoma of Lung

45-year-old male with stage 4 Adeno carcinoma of the lung. The tumor was found to obstruct the left superior lobe bronchus with subsequent subtotal athelectasis and retracted left hemi-thorax. The exam found diffuse thickening of the mediastinal pleura, lymphadenopathy and analogous formations of probable secondary nature. In the expert's opinion, if the patient is already at stage IV, he should not undergo surgery. He recommends combined endobronchial and external irradiation together with chemotherapy.

Multiple Sclerosis (MS)

41 year-old male was recently diagnosed as having multiple sclerosis (MS) after episodes of leg and shoulder weakness and parasthesis. Lately he experiences dizziness. His MRI showed several demyelinating lesions, other ancillary tests showed demyelinating damage to the auditory and visual pathway. Currently he has no functional or sensorial deficiencies. He was offered several immunomodulatory treatment options: Rebif, Betaferon and Copaxone, and asks about their pros, cons and complications, and about the differential diagnosis.

SOL (Space occupying lesion) of brain

33-year-old female underwent an episode of dizziness followed by speech disturbances and some right hand weakness. Her physical exam showed very mild signs of right cerebelar dysfunction. The MRI found mid-Vermian Cavernoma with clear signs of past bleeding and Bulging into the fourth ventricle. A surgery for resection of the cavernous malformation was recommended.

Small Cell Neuroendocrine Tumor of the Cervix – additional opinion

36-year-old otherwise healthy female presented with an atypical pap smear. Biopsy of cervix revealed poorly Differentiated Neuroendocrine Carcinoma. Immunohistochemical staining showed the cells positive for NSE, SYN, CHR, and 90% positive for Ki67 (proliferative index). The findings of the PET-FDG test showed pathological absorption of FDG as a primary tumor of the cervix, towards the left side of the body. Moreover, evidence is seen of nodal metastatic spread in the retroperitoneum and pelvis, mainly on the left.

Tentorial Meningioma

66-year-old female underwent a left suboccipital craniotomy for resection of a tentorial meningioma. The postoperative course has been difficult, marked by deterioration associated with posterior temporal and cerebellar edema and hemorrhage. First she seems to be in good general conditions showing only a slight strength deficiency in the left upper limb, but about a month after the surgery she started showing asthenia and melena, and esophageal gastroduodenoscopy revealed a sclerosis of active arterial bleeding from duodenal ulcer.

Post Traumatic Double Pelvic Fracture

73-year-old female with history of backache and diagnosis of Adult Scoliosis, fell down getting a back trauma at the level of the left hip and inferior limb. After severe symptomatic worsening X-ray examination was performed. The findings were: asymmetric pelvis, bilateral coxarthrosis, coarse arthrosic and osteophytosic manifestations, discopathies and disc arthrosis. The prescribed therapy included Piroxicam, Tioside, Depalgos, and low-molecular-weight-heparin therapy that was later replaced by NSAIDs by injection