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The therapeutic value of history and physical examination has long been recognised but little evidence exists to support its teaching in the undergraduate context. This article describes demonstrating therapeutic examination to year four students at Brighton and Sussex Medical School. A student volunteer is invited to be the patient. The presentation is clearly marked as a 'middling case' of sore throat, i.e. one where the condition is painful but not dangerous. In this example I explain that the patient has a Centor score of 2-3 and that my examination seeks to be therapeutic to the patient and the GP. The demonstration highlights the importance of practical preparation (one's clinical equipment laid out), physical touch (e.g. starting with the hands/pulse as non-threatening), some 'technology' (e.g. pulse oximeter), demonstrating thoroughness and using reassuring language during the examination. Students are reminded that therapeutic examination may elicit important clinical signs, e.g. atrial fibrillation or hypertension. The session consistently receives positive quantitative and qualitative feedback. The latter reveals that some students would prefer teaching focused on specific diagnoses (rather than their absence). Here I present my own model of the 'craft' of general practice called TPAP: Trust built upon implementing the Process (history, examination, basic tests, incremental management etc), Art (thinking strategically) and Practice ('knowing one's tools') of medicine. Finally, this article considers the important notion of 'conserving clinical energy' and makes the claim that effort expended upon the physical examination reaps benefits later in the consultation and in forging long term therapeutic relationships.

Increasingly, protocols have been developed to optimize obstetric anesthesia care. However, there is a paucity of data on adherence to these guidelines. The primary aims of this study were to utilize the Multicenter Perioperative Outcomes Group (MPOG) database to estimate (1) the rate of adherence to best practice guidelines for cesarean delivery (CD) (2) the association of case- and hospital-level factors with adherence, and (3) the percentage of variability in adherence attributable to the patient-, case-, and hospital-level factors. We performed a multicenter, observational cohort study utilizing the MPOG database to review all CDs in women aged 15-44. Best practices were defined based on societal guidelines and included timely antibiotic administration, post-spinal SBP maintenance >90 mmHg, general anesthesia (GA) avoidance, prevention of perioperative hypothermia, use of low-dose neuraxial morphine, post-spinal vasopressor infusions, and spinal needles ≥ 25-gauge. Covariates of interest included patient-, case-, and hospital-level factors. We analyzed 289,047 CD cases in the MPOG database from 2015-2022. The following adherence outcomes were observed: timely antibiotic administration, 86.2% (99%CI: 86-86.3%); post-spinal SBP maintenance, 96.7% (99%CI: 96.6-96.8%); avoidance of GA, 97.0% (99%CI: 96.9-97.0%); prevention of perioperative hypothermia, 56.7% (99%CI: 56.5-56.9%); use of low-dose neuraxial morphine, 74.2% (99%CI: 74.0-74.5%); use of post-spinal vasopressor infusion, 55.4% (99%CI: 55.1-55.8%); and use of ≥ 25-gauge needle for spinal anesthesia, 89.0% (99%CI: 88.6-89.4%). Poorer adherence correlated with factors at the patient- (ASA Physical Status ≥ 4), case- (evening or overnight CD), and institution-level (absence of obstetric fellowship or "Center of Excellence" status). Among our large cohort of CD cases, overall adherence to guideline-supported best practices was variable, with post-spinal vasopressor infusions being the lowest and avoidance of GA being the highest. Targeted interventions addressing these factors may improve quality and promote more optimal care.

Pharmacotherapy is a core competence for physicians and students' learning is guided by examinations. This study aimed to examine medication-related examination questions across clinical courses spanning four semesters within a Swedish medical programme. In total, 375 questions used in four examinations (spring 2025; University of Gothenburg) were categorised independently, followed by consensus discussions, into mutually exclusive groups. In the first step, it was determined whether a question was medication-related; if so, the second step involved categorising its content according to the WHO 6-Step Model, which structures the physician 's pharmacotherapeutic workflow from defining the patient's problem (differential diagnosis) and the therapeutic goal, to selecting and prescribing appropriate medications, counselling, and planning for monitoring and follow-up. Ninety-four (25%) questions were related to medications, and an additional 44 (12%) included medications but they were not the primary focus. Half of the medication-related examination questions concerned general medication knowledge, including items where a condition was to be matched with the standard treatment (n = 47). The remaining questions (n = 47) addressed the first (n = 8), second (n = 5), third (n = 33), and fifth (n = 1) steps of the WHO 6-Step Model. No questions were related to the fourth and sixth steps. Pharmacotherapeutic aspects appeared as an integral component of written examinations in undergraduate clinical courses, but the questions often concerned drug selection and factual recall; other steps in the WHO Model deserve attention in other assessment procedures, including pharmacotherapy-related differential diagnosis, goal setting, technical aspects of prescribing, patient counselling, and follow-up monitoring.

To illuminate the meanings of encountering patients in a suicidal process from the perspective of ambulance clinicians. Narrative interviews were conducted with eighteen ambulance clinicians in Sweden. Data were analyzed using a phenomenological hermeneutical approach inspired by the philosophy of Ricœur. The main theme, "Navigating a fragile capability," reveals a profound tension within professional identity. Traditionally anchored in technical agency, this identity is challenged by a movement toward vulnerability and shared humanity. Capability in these encounters is defined not only by medical problem-solving but by the courage to remain present during existential crises. Entering the patient's narrative imposes an extensive responsibility, where experiences of indecisiveness and powerlessness emerge as expressions of moral sensitivity rather than professional inadequacy. Encountering suicidal patients reveals professional capability as a fragile construct dependent on reciprocity, requiring a shift from technical agency toward an ethical presence when medical protocols reach their limit. By validating being with as a clinically meaningful component of care, the encounter moves beyond procedural care toward a meaningful ethical aim. Practically, professional standards must expand beyond technical management to integrate relational competence and existential care as core elements of prehospital practice.

Cutaneous mucormycosis is a rapidly progressive and often fatal fungal infection predominantly affecting immunocompromised hosts, with post-transplant patients being particularly vulnerable due to immunosuppressive regimens and metabolic derangements. Despite its high mortality, especially in the context of surgical-site involvement, optimal therapeutic strategies remain underexplored. We present a rare case of surgical-site mucormycosis in a renal transplant recipient with poorly controlled diabetes, successfully managed using adjunctive topical antifungal therapy, highlighting a potential treatment strategy in immunosuppressed populations. A middle-aged male with chronic kidney disease, recent renal transplantation, and persistent hyperglycemia developed a non-healing surgical-site wound. Early clinical suspicion led to a bedside potassium hydroxide mount and expedited fungal cultures, which revealed mucormycosis. The patient was promptly initiated on systemic liposomal amphotericin B and, uniquely, adjunctive topical amphotericin B applied directly to the wound bed. Despite the challenges of ongoing immunosuppression, renal dysfunction, and glycemic instability, the patient demonstrated significant local and systemic improvement without the need for disfiguring surgical debridement. This case underscores the diagnostic value of bedside fungal microscopy in resource-limited and time-sensitive settings, where conventional culture and histopathology may be delayed. The clinical decision to incorporate topical amphotericin B, an underutilized yet mechanistically sound adjunct, was based on the rationale of high local fungal burden, systemic drug toxicity concerns, and limited evidence in immunosuppressed surgical cohorts. This approach not only curtailed disease progression but also preserved graft integrity and patient quality of life. This case highlights the under-recognition of mucormycosis in post-transplant surgical wounds and the absence of standardized topical antifungal protocols, representing a critical gap in transplant infectious disease management. This case report highlights that early bedside diagnosis, combined with individualized adjunctive topical amphotericin B, may help control post-transplant surgical-site mucormycosis, reduce the need for morbid surgical interventions, and warrants further evaluation for incorporation into future treatment guidelines for high-risk immunocompromised patients.

Ear, nose and throat (ENT) foreign body (FB) is common problem with significant morbidity and mortality. They are classified into organic or inorganic. Aerodigestive FBs are responsible for suffocation and death up to three years old with a 10% mortality up to 14 years old in Europe. Malaysia lacks local data that quantifies FB in dimensions to predict its risk. The study objectives were to determine the incidence of ENT FBs (paediatric and adult) in a Malaysian tertiary referral center; to determine the association between the FB types and factors contributing to its occurrence (largest dimension, volume, witnessed); to determine the treatment required; and association between hand dominance with ENT FBs. Prospective data of all children (<18 years old) and adults (&#x2265;18 years old) seen by the ENT physicians presenting with ENT foreign body were included over 12 months at Hospital Canselor Tuanku Muhriz (HCTM) from 1st February 2017 to 31st January 2018. All cases are seen by an ENT doctor (specialist and/or medical officer) during on-call, in hospital and outpatient's referrals. FB dislodged in the lower airways (trachea, bronchus and bronchiole) and upper gastrointestinal (GI) tract (oesophagus) were included. Exclusion criteria were FB dislodged in non-ENT orifices such as the stomach and beyond with no other ENT FBs. Bias was reduced by a proforma after obtaining an informed consent and taking the average of three measurements of FB dimensions. The incidence of ENT FB within HCTM was 3.5% (overall), 1.9% (organic), 1.6% (inorganic); 1.65% (children) and 1.85% (adults). Children have a mean age of 5.34 and adults 49.35 years. Among the patient factors; children FB are often inorganic (73.95%; plastic, metal, graphite), males predominant (56.5%), unwitnessed (66.67%), witnessed incidents were by adults (69.5%) at home (91.3%). Adult FB are often organic (77.1%; fish bone, cotton, tick), male to female ratio 1.4:1; not associated with occupation. Mackerel followed by red snapper and tilapia were common fish bones ingested. Common locations of FB among children and adults were throat (35.3%), ear (32.03%) and nose (26.14%). Less than one fifth required hospitalization due to aerodigestive FBs with 6 (72.7%) of hospitalised patients suffering complications of hypoxic brain injury, lung collapse, pneumonia, esophageal perforation and lacerations. Fifty-seven (37.25%) patients (adults predominant) required endoscopic removal under general or local anaesthesia. The side of ear and nose FB to hand dominance was significant (p<0.05). ENT FB are more common in the ear and nose in children; not witnessed, located in the oropharynx and occurred at home and during playtime. Organic FB and fish bones were common among adults in the Malaysian population. Aerodigestive FBs are associated with hospitalization, complications, requiring antibiotics and endoscopic intervention.

Alphavirus chikungunya is an arbovirus transmitted by Aedes mosquitoes and typically presents with acute-onset fever and severe polyarthralgia. In a subset of patients, joint symptoms may persist beyond the acute phase, leading to prolonged functional impairment. With increasing international travel, imported chikungunya infections have become an important consideration in non-endemic countries. In this report, we present a 58-year-old woman who was diagnosed with imported chikungunya infection after returning from Cuba, presenting with fever and widespread joint pain. On initial evaluation, C-reactive protein levels were markedly elevated, while procalcitonin levels remained within normal limits. The diagnosis was confirmed by demonstrating chikungunya virus-specific IgM positivity and IgG seroconversion in sequential serum samples. Viral RNA was not detected in molecular assays. Dengue, Zika, and other arboviral infections, as well as rheumatologic diseases, were excluded during the differential diagnosis. Despite treatment with antipyretics and non-steroidal anti-inflammatory drugs, the patient's joint pain persisted and significantly limited daily activities, necessitating opioid analgesics. Based on the persistence of symptoms beyond the acute phase but for less than three months, the clinical picture was consistent with subacute (post-acute) chikungunya-associated inflammatory arthralgia. Systemic corticosteroid therapy was initiated, resulting in partial clinical improvement. Disease-modifying antirheumatic drugs were not started, as the criteria for chronic chikungunya arthritis were not met. This case highlights the importance of considering chikungunya infection in travelers returning from endemic regions who present with fever and persistent arthralgia, even in the absence of rash. Early recognition and appropriate management during the subacute phase are crucial to improve patient outcomes and prevent progression to chronic disease.

Coronary-subclavian steal syndrome (CSSS) is an uncommon but clinically important entity that may occur after coronary artery bypass grafting (CABG) with internal mammary artery conduits. Hemodynamically significant proximal left subclavian artery (LSA) stenosis can alter distal branch vessel flow and, in patients with prior left internal mammary artery (LIMA)-based CABG, may raise concern for coronary-subclavian steal physiology. Concurrent vertebral artery flow reversal may further predispose to cerebrovascular insufficiency. We report a case of a 75-year-old male with an extensive cardiovascular history, including prior CABG, transcatheter aortic valve replacement (TAVR), thoracic endovascular aortic repair (TEVAR), and a cardiac implantable electronic device, who presented with dizziness and was found to have severe proximal left subclavian artery stenosis. Computed tomography angiography demonstrated severe (~90%) proximal LSA stenosis, while duplex ultrasonography revealed alternating vertebral artery flow consistent with evolving steal physiology. Invasive hemodynamic assessment confirmed a significant trans-stenotic gradient (>25 mmHg). Given the patient's prior LIMA-based CABG, severe proximal LSA stenosis raised concern for possible coronary-subclavian steal physiology, although direct angiographic confirmation of retrograde LIMA flow was not available. The patient underwent a hybrid endovascular approach utilizing intravascular ultrasound (IVUS)-guided lesion assessment and optimization, drug-coated balloon (DCB) angioplasty, and precise deployment of a balloon-expandable covered stent (GORE&#xa0;VIABAHN&#xa0;VBX; Flagstaff, AZ: W. L. Gore & Associates). The procedure restored antegrade subclavian flow, normalized the trans-stenotic pressure gradient, and preserved the vertebral artery origin. This case demonstrates the technical feasibility of a multimodality endovascular approach for severe proximal LSA stenosis with evolving vertebrobasilar steal physiology in a high-risk post-CABG patient. Integration of IVUS guidance, DCB therapy, and covered stent technology may assist procedural optimization in carefully selected patients, although further studies are required to define the long-term role of this strategy in supra-aortic trunk disease.

The yellow fever vaccine containing the live attenuated 17D strain is one of the most effective methods for preventing yellow fever infection and has long been considered safe. However, rare but serious adverse events such as yellow fever vaccine-associated viscerotropic disease (YEL-AVD) have been reported. YELAVD is a life-threatening clinical condition that can mimic wild-type yellow fever infection, is associated with a high risk of mortality, and may pose diagnostic challenges, particularly in non-endemic regions. A 57-year-old male patient with no underlying comorbidities, history of immunosuppression, or thymic pathology presented with a high fever that began two days after yellow fever vaccination and had persisted for seven days at the time of admission. Physical examination revealed hypotension and jaundice; hemodynamic stability was achieved with intravenous fluid resuscitation. Laboratory findings demonstrated thrombocytopenia and hepatic dysfunction. Infectious etiologies, including malaria, dengue fever, West Nile virus infection, and Crimean-Congo hemorrhagic fever, as well as other possible causes, were comprehensively and systematically excluded; no etiological findings were identified in blood cultures or imaging studies. Although polymerase chain reaction (PCR) testing for yellow fever virus was negative, the presence of two major Brighton Collaboration criteria-hepatic involvement and thrombocytopenia-together with the systematic exclusion of alternative etiologies supported the classification of this case as consistent with level 2 diagnostic certainty for YEL-AVD. The patient fully recovered with supportive treatment without requiring intensive care. To the best of our knowledge, this is the first reported case of YEL-AVD from T&#xfc;rkiye. The increasing number of international travel from non-endemic to endemic regions and the expanding use of vaccination highlight the need for increased clinical awareness of rare but serious adverse events such as YEL-AVD. This case emphasizes the importance of early assessment of vaccination history in the differential diagnosis and underscores the value of case reports in global vaccine safety surveillance.

Among the various treatments for type 2 diabetes during the initial period, glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and sodium-glucose cotransporter 2 (SGLT2) inhibitors have been considered together as agents with separate cardiometabolic benefits, given their limited glucose-lowering effects. GLP-1 RAs are reported to inhibit atherosclerosis through several physiological processes, including increased blood flow in endothelial tissues, decreased inflammation, increased antioxidant levels, and improved lipid profile. There is a similar situation with SGLT2 inhibitors, and the explanation for this is different yet complementary, as these drugs cause a decrease in both cardiac preload and afterload and, at the same time, increase vascular permeability, diuresis, and more efficient energy usage by the heart. Thus, they have been affirmed by extensive clinical trials, which show that, although these drugs may harm patients, they do not result in significant cardiovascular events, have a lower treatment rate for heart defects, and are associated with a longer time before the patient's renal function deteriorates. This translates into a continuing shift toward the dominion in terms of cardiometabolic protection - a strategy that is receiving strong backing from the majority of clinical guidelines across the world.

The patient was a pregnant 30-year-old gravida 6, para 0 (G6P0) woman at 22 weeks and four days (22w4d)&#xa0;with myelomeningocele and neurogenic bladder who presented with progressive pain, fevers, chills, and transaminitis concerning for urosepsis requiring emergent cystolithalopaxy. Preoperative evaluation identified marked lower-extremity weakness. Anesthetic considerations included the safety of neuraxial anesthesia and concerns regarding neuromuscular blockade and reversal. Neuraxial anesthesia was avoided due to myelomeningocele, and succinylcholine was avoided due to concern for hyperkalemia. Rocuronium was used, with sugammadex administration for neuromuscular blockade reversal following consultation with obstetrics. The case proceeded uneventfully.

When visceral leishmaniasis occurs alongside human immunodeficiency virus (HIV) infection, the clinical picture is more severe and the diagnosis and treatment processes are more complex. This case study presents the clinical findings, diagnostic approaches and treatment process of a patient diagnosed with concurrent indigenous visceral leishmaniasis and HIV. A 60-year-old individual who had recently been diagnosed with HIV was admitted for further investigation due to persistent pancytopenia despite receiving antiretroviral therapy. Physical examination, laboratory tests and imaging revealed no findings other than hepatosplenomegaly and generalised lymphadenopathy. Investigations failed to reveal any evidence of common opportunistic infections or HIV-associated malignancies. Upon re-evaluation of the patient's history, it emerged that he lived in a village where there were sheepdogs nearby. Peripheral blood tests revealed positive results for Leishmania IFAT (1/1024), the rK39 rapid antigen test, the Giemsa-stained smear test and polymerase chain reaction (PCR) testing. Promastigote forms were observed in NNN medium and PCR testing identified the species as L.infantum/donovani. Primary treatment with liposomal amphotericin B was administered at a total dose of 50 mg, followed by secondary prophylaxis every four weeks. No clinical or laboratory findings suggestive of relapse were detected during follow-up. The patient died four weeks after the last prophylactic dose due to a myocardial infarction, which was thought to be related to a diagnosis of congestive heart failure. This case is noteworthy for two reasons: it is the second reported case of HIV and visceral leishmaniasis co-infection in T&#xfc;rkiye, and it demonstrates the application of secondary prophylaxis. It makes a unique contribution to the literature in T&#xfc;rkiye by demonstrating the applicability of peripheral blood-based diagnostic approaches and molecular typing in cases of Leishmania co-infection with HIV.

Determination of the efficacy of Sirhy's transverse peeling technique, a modification of traditional deep sclerectomy that involves the creation of a wider and longer deep scleral flap to increase aqueous humor drainage. This was a retrospective cohort study conducted on patients who underwent deep sclerectomy using the transverse peeling technique for the management of glaucoma. Complete success was defined as an intraocular pressure of &#x2264; 21 mmHg when the patient was off all intraocular pressure-lowering medications. However, qualified success was defined as an intraocular pressure of &#x2264;21 mmHg when the patient was on additional intraocular pressure-lowering medication or laser goniopuncture. Failure was classified as an intraocular pressure of >21 mmHg at 6&#xa0;months or the need for additional glaucoma interventions. Forty-one eyes and 39 patients were included in this study. The mean preoperative intraocular pressure was 21.78&#xa0;&#xb1;&#xa0;7.62 mmHg, which was significantly reduced to 13.76&#xa0;&#xb1;&#xa0;3.95 mmHg postoperatively, with a complete success rate of 80.5%, a qualified success rate of 17.1%, and a failure rate of 2.4%. Deep sclerectomy using the transverse peeling technique is a novel approach that results in better control of intraocular pressure, a reduced need for post-operative antiglaucomatous medications, and a decreased requirement for goniopuncture.

Glioblastoma multiforme (GBM) is an aggressive primary brain tumor associated with poor prognosis, rapid functional decline, and psychological distress. An updated review of the literature is lacking, despite that patients with GBM appear to be among the highest risk for suicide among cancer patients. This review summarizes up-to-date evidence of suicide risk factors, screening approaches, and suicide mitigation strategies in patients with GBM. Suicide risk is the highest in the first year following GBM diagnosis. It is also associated with older age, male gender, and tumor-related factors such as supratentorial location. Other factors such as neurocognitive decline and poor functional status may also contribute. Evidence emerging from broader oncology populations suggests that demoralization and existential distress may be factors, though these have not been studied in GBM cohorts. Treatment-related psychiatric adverse effects from corticosteroids, anti-epileptic drugs, chemotherapy, and radiotherapy may also influence psychiatric illness and mediate suicide risk. Screening tools such as the Patient Health Questionnaire-9, Hospital Anxiety and Depression Scale, and Colombia-Suicide Severity Rating Scale have been effectively used to screen for suicide in conjunction with clinical interviewing in GBM patients. Evidence-based suicide reduction interventions include psychotherapy, safety planning, lethal means restriction, and caregiver support. GBM is a diagnosis that is associated with higher rates of suicide than almost all other cancers, and the extant literature identifies demographic and tumor features that are associated with suicide in this population. Effective interventions exist to identify and support these patients. Future studies should systematically measure risk factors identified in broader oncology populations to identify additional GBM-specific risk factors for suicide.

Acute appendicitis is a leading cause of acute abdomen, yet its onset after blunt trauma remains exceedingly rare and diagnostically challenging - particularly in the elderly and in patients with concurrent neurological injuries. We present the case of a 65-year-old woman who developed acute appendicitis following a motor vehicle collision that also caused thoracic spinal fractures with canal involvement. Initially hemodynamically stable with a normal abdominal examination and a negative focused assessment with sonography for trauma, she developed right lower quadrant pain 22 h posttrauma, which localized and intensified by 56 h. Contrast-enhanced computed tomography (CT) at 59 h revealed an 8-mm inflamed appendix with periappendiceal fat stranding, and open appendectomy at 61 h confirmed acute appendicitis with fibrous obliteration. The patient's recovery was uneventful. This case underscores how concurrent spinal injury and immobilization can obscure evolving abdominal pathology, emphasizing the importance of repeated clinical assessment and timely CT imaging in elderly polytrauma patients. In addition to the case presentation, we conducted a comprehensive literature review of all reported cases of posttraumatic appendicitis, summarizing demographic, clinical, and diagnostic patterns to contextualize this rare phenomenon. Together, these findings reinforce the need for heightened diagnostic vigilance and multidisciplinary coordination when evaluating delayed abdominal pain in trauma patients with neurological compromise.

We report two cases of parturients with HELLP syndrome who were diagnosed with subcapsular liver hemorrhage (SLH) during an emergency cesarean section. In case 1, a 30-year-old woman who was pregnant at 34+&#xa0;weeks was admitted because of fetal heart rate deceleration. On the third day of hospitalization, the patient experienced upper abdominal pain. Considering the diagnosis of HELLP syndrome, an emergency cesarean section was performed under general anesthesia. Multiple SLH sites were discovered during laparoscopic exploration, but no intervention was performed. After surgery, the patient's platelet count, transaminase levels, and other indicators gradually returned to nearly normal levels. In case 2, a 30-year-old woman was admitted to the hospital at 34&#xa0;+&#xa0;1&#xa0;weeks of pregnancy with elevated blood pressure for 1&#xa0;week and thoracodorsal pain for 1 day. An emergency cesarean section was performed under general anesthesia. We performed laparoscopic exploration and identified SLH in the right liver near the diaphragm without obvious active bleeding. No further interventions were performed. The patient recovered well after surgery and was discharged on the fifth day after surgery. Our report suggests that thoracodorsal pain may be an early symptom of SLH, and the incidence of SLH may be underestimated. Even with negative imaging results, SLH cannot be ruled out, and clinicians need to pay sufficient attention to actively prevent and treat it. Even if the ultrasound examination is negative, SLH cannot be completely excluded, and conservative treatment is advisable under specific circumstances. preeclampsia, HELLP syndrome, pregnancy, cesarean section, liver.

Osmotic demyelination syndrome (ODS) occurs due to rapid shifts in serum sodium levels and osmolality, resulting in neuronal damage. While it is most often caused by the rapid correction of chronic hyponatremia, other electrolyte imbalances have also been identified as potential triggers. Risk factors include alcohol abuse, malnutrition, and liver disease, among others, with common symptoms including tetraparesis, dysphagia, and altered consciousness. We report the case of a 45-year-old male with alcohol dependence who presented to the emergency department with hypernatremia (154 mmol/L), altered mental status, and slurred speech. Despite gradual sodium correction, his condition deteriorated, and head MRI revealed findings consistent with central pontine myelinolysis and Wernicke's encephalopathy. After 5 months of hospitalization for severe ODS, including the need for a tracheostomy and gastrostomy, extensive rehabilitation enabled the patient to regain full independence in daily activities. This is a rare case of ODS presenting with hypernatremia in the setting of dehydration, malnutrition, and alcohol dependence. A preceding chronic osmotic adaptation, possibly related to unrecognized hyponatremia, may have contributed, although this could not be confirmed. Early detection, aided by MRI, was critical. Despite the severity of ODS, gradual correction of hypernatremia and extensive rehabilitation led to substantial recovery, highlighting the importance of long-term management and rehabilitation in improving patient outcomes.

Renal cell carcinoma (RCC) usually presents with the classic three signs: flank pain, blood in the urine, and a palpable mass in the abdomen. We present a case of a 54-year-old woman who exhibited altered bowel habits. Cholecystectomy was scheduled after the identification of gallstones; however, a preoperative CT scan inadvertently disclosed RCC. The tumor affected the renal vein and extended into the ureter. The patient underwent a radical nephrectomy, during which the renal vessels were tied off with Vicryl sutures, and the ureter was cut up to the vesicoureteral junction. To our knowledge, this constitutes an uncommon incidental discovery of clear cell carcinoma in a patient lacking typical RCC symptoms, demonstrating intraluminal extension into the ureter. This pattern of dissemination is not delineated in the current literature, nor is it referenced by the existing AJCC staging system. This case may indicate the necessity for reevaluation or alteration of the AJCC guidelines to accommodate intraluminal ureteric extension in clear cell RCC.

Endometriosis is a benign yet chronic gynecologic condition that, in rare cases, may undergo malignant transformation. Although endometriosis-associated malignancies most commonly arise in the ovary, extragonadal sites may also be affected. Endometriosis-associated intestinal tumors (EAITs) are exceptionally rare and often difficult to diagnose. We report the case of a 73-year-old woman with a remote history of total hysterectomy and bilateral salpingo-oophorectomy for endometriosis who presented with rectal bleeding and constipation. Imaging and colonoscopy revealed a nearly obstructing mass in the sigmoid colon, initially suspected to be primary colorectal carcinoma. Biopsy demonstrated a poorly differentiated carcinoma with squamous features. Immunohistochemical analysis supported a M&#xfc;llerian origin, an unexpected finding given the patient's prior gynecologic surgery. Sigmoidectomy subsequently revealed a high-grade endometrioid carcinoma with extensive squamous differentiation arising from intestinal endometriosis. This rare case highlights that endometrioid carcinoma can develop from intestinal endometriosis decades after definitive gynecologic surgery. Accurate diagnosis requires the integration of clinical history, histopathological findings, and immunohistochemical results to differentiate this entity from primary colorectal carcinoma. Increased awareness of EAITs is essential to ensure accurate diagnosis and appropriate management.