Online
Clinical Case Study (December 2003)
Clinical
Cardiology Series
臨床心臟科個案研究
The
content of the Clinical Cardiology Series is provided by:
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.),
F.R.C.P. (Edin.), Specialist in Cardiology
臨床心臟科個案研究之內容誠蒙王壽鵬醫生及李少隆醫生提供。
A 67 year old lady
with chronic congestive heart failure comes to your office. Her left ventricular
ejection fraction was 30% by echocardiogram and she also has chronic renal insufficiency
with a creatinine level of 250 umol/l. She is currently put on an ACE inhibitor
(ACEI), an angiotensin - receptor blocker (ARB), a beta-blocker, spironolactone
and digoxin.
Answers
| 1. |
Is
ACE inhibitor contraindicated in heart failure patients with mild to moderate
renal impairment?
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patients with
mild to moderate renal impairment? No. In CONSENSUS (The Cooperative North
Scandinavian Enalapril Survival Study), 35% patients assigned to the ACEI
arm had increases in serum creatinine level of 30% or more at the first
follow-up visit but in most patients, the creatinine level returned to
baseline level by the follow-up measure even without a reduction in the
ACEI dose.
Current evidence
suggests that ACEI improves survival in patients with heart failure and
moderate renal insufficiency, although the risk/benefit ratio in patients
with severe renal insufficiency is still unclear.
Therapy should
be started with low initial dose when patients are volume replete and
the dose should be titrated up gradually with careful monitoring of renal
function and serum electrolytes particularly potassium. NSAIDs should
be avoided if possible.
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| 2. |
Is
ARB contraindicated in heart failure patients with mild to moderate renal
impairment?
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No. The same
precautions for ACEI should be observed.
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| 3. |
Is
beta-blocker contraindicated in heart failure patients with mild to moderate
renal impairment?
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No, although
none of the large clinical trials of beta-blockers in heart failure has
reported any subgroup analyses for patients with renal insufficiency.
As metoprolol and carvedilol are predominantly metabolized by the liver,
they may be safer than nadolol and atenolol.
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| 4. |
Is
spironolactone contraindicated in heart failure patients with mild to
moderate renal impairment?
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No, but hyperkalemia
is a notable complication in these patients particularly when the renal
insufficiency is of moderate to severe degree. A low dose of 25mg/day
should be used and the drug should be withheld when the patient develops
illnesses that predispose the patient to hypovolemia.
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| 5. |
Is
digoxin contraindicated in heart failure patients with mild to moderate
renal impairment?
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No, but the
drug clearance would be impaired. To avoid digoxin overdose, therapy should
be maintained at a low dose with frequent monitoring of the serum drug
level.
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Dermatology Series
皮膚科病例研究
A 50 year old British
engineer presented with a nodule on his right cheek. The lesion was only noted
for two weeks. This started as a pea-sized papule which rapidly enlarged over
this period. The lesion was asymptomatic. He denied any history of trauma or
insect bite. He enjoyed good general health with no significant medical or surgical
illness. Physical examination revealed a nodule measuring 1.2 cm in diameter.
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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. |
What
is the clinical diagnosis? |
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Keratoacanthoma,
solitary type.
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| 2. |
What
is the most important differential diagnosis?
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Squamous cell
carcinoma (SCC).
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| 3. |
What
is classical description of this condition? |
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Solitary keratoacanthoma
classically presents as a rapidly enlarging, locally destructive, dome-shaped,
skin-coloured, firm nodule with a central keratin-filled crater. It shares
features with SCC and histologically mimics a low grade SCC. Hence, keratoacanthoma
can be considered as abortive form of SCC. Although keratoacanthoma is
usually self-healing, its course can be unpredictable.
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| 4. |
What
are the risk factors for this condition? |
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Risk factors
include sun exposure, old age and fair-skin persons.
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| 5. |
What
are the treatments?
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Treatment
modalities include electrodessication, curettage, intralesional injection
of fluorouracil or bleomycin, radiotherapy and surgical excision. Surgical
excision has the advantage of complete tumour removal in one setting and
availability for histopathological evaluation.
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