Online Clinical Case Study (March 2003)

Clinical Cardiology Series
臨床心臟科個案研究

The content of the Office Cardiology Series is provided by:
Dr. Chan Chi Wo
M.B.Ch.B.(C.U.H.K.), M.R.C.P.(U.K.), F.H.K.C.P., F.H.K.A.M., Specialist in Cardiology
Dr. Wong Shou Pang, Alexander
F.R.C.P., F.H.K.A.M.(Med.), F.H.K.C.P., Specialist in Cardiology
Dr. Li Siu Lung, Steven
M.B.,B.S.(H.K.), M.R.C.P.(U.K.), F.H.K.A.M., F.H.K.C.P., F.R.C.P.(Glasg.), Specialist in Cardiology
臨床心臟科個案研究之內容誠蒙陳志和醫生、王壽鵬醫生及
李少隆醫生提供。

 

 

Answers

1. A 65 year old gentleman with prior history of hypertension and ischaemic heart disease attends your office for a compliant of palpitation; his heart rate is 150/min. What is the rhythm shown on the above ECG on admission?

Atrial flutter with 2:1 AV conduction

The sawtooth waveforms of atrial flutter are usually seen in the inferior leads II, III and aVF. Sometimes the rapid atrial rate can be seen in V1 also. Atrial flutter with 2:1 block should be suspected when a rate of about 150 bpm is seen.
 

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2.

Would you name the treatment modalities available to tackle atrial flutter?

1. Pharmacological therapy; 2. Electrical cardioversion and overdrive pacing; 3. Catheter Ablation.
 

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3. What is the most important determinance governing whether immediate cardioversion is needed?
 

Haemodynamic condition - blood pressure. However, other causes of hypotension should not be overlooked as each of them warrants a specific therapy of its own. It is especially worth remembering when, for example, in this case the apical rate is only 150/min.
 

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4. Apart from excluding electrolyte disturbance, hyperthyroidism and sepsis if clinically indicated, what cardiac investigation should you arrange for this gentleman?
 

The frequent association between Atrial Flutter and other cardiac defects necessitates an echocardiograhic examination.
 

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5. Would you consider long-term anticoagulation for this gentleman if his atrial flutter persists?
 

It advisable to anticoagulate patients aged more than 65 with atrial flutter unless the duration of the arrhythmia <48 hrs or lone atrial flutter with preserved left ventricular function is present.
 

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  Reference:
Contemporary Management of Atrial Flutter. Circulation. 2002; 106: 649-652.

Dermatology Series 皮膚科病例研究

A 30 year old female clerk complained of a two years' history of abnormal-looking thumb nails. This was not accompanied with pain or itch. She denied history of excessive wet-work. She enjoyed good past health with no history of skin or nail diseases. She applied over-the-counter topical medicaments but no improvement was seen.

The content of the Dermatology Series is provided by:
Dr. Tang Yuk Ming, William and Dr. Chan Loi Yuen
Specialist in Dermatology & Venereology
皮膚科病例研究之內容誠蒙鄧旭明醫生及陳來源醫生提供。

 

Answers

1. Describe the features seen in the clinical photo.

The central part of both thumb nails is longitudinally grooved with adjoining transverse furrows and ridges giving a fir-tree appearance. The lunula is prominent. Hang nails which are flakes of nail fold skin and loss of nail cuticle are also evident.
 

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2.

What is the most likely diagnosis?

Median nail dystrophy.
 

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3. What is the cause of the nail condition?

Median nail dystrophy is a consequence of repeated and often self-inflicted trauma resulting from a habit or tic like rubbing of thumb nail by adjacent fingers. Nails with prominent lunula are more susceptible to developing the condition.
 

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4. What are the differential diagnoses?

The differential diagnoses include onychomycosis, lichen planus, periungual eczema, and proximal nail fold tumours. The clinical features of onychomycosis include discoloration, subungual thickening, onycholysis, and crumbling of nail plate. These features are not prominent in median nail dystrophy. Nail scraping in median nail dystrophy for fungal culture is negative. In lichen planus; nails showed irregularity and thinning at early stage, and atrophy at later stage. At the end stage, a pterygium obliterating the proximal nail fold may be formed. In periungual eczema; there may be nail distortion and loss of cuticle but not a fir-tree pattern. Tumours such as myxoid cysts and warts affecting the proximal nail fold may exert pressure on the nail matrix resulting in a longitudinal depression on the nail plate.
 

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5.

What is the treatment?

Patient should not rub or scratch the nail. The nail can also be wrapped to protect from trauma.
 

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