Online Clinical Case Study (May 2005)

Clinical Cardiology Series
臨床心臟科個案研究

The content of the Office Cardiology Series is provided by:
Dr. So Yui Chi
M.R.C.P. (U.K.), M.R.C.P. (Ireland), M.H.K.C.P.
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
Dr. Wong Shou Pang, Alexander
F.R.C.P., F.H.K.A.M.(Med.), F.H.K.C.P., Specialist in Cardiology
臨床心臟科個案研究之內容誠蒙蘇睿智醫生、李少隆醫生王壽鵬醫生提供。

A 30 year old gentleman, who enjoyed good past health, complained of recent fast palpitations that were abrupt in onset. One day, he visited the ER department with palpitations that lasted for more than 1 hour. On admission, the blood pressure was 120/70 mmHg. ECG was done and was shown below.

Answers

1.

What is your diagnosis?
a. SVT with aberrancy
b. Atrial fibrillation with aberrancy (AF)
c. Ventricular fibrillation (VF)
d. Ventricular tachycardia (VT)

Option D is correct.

This patient has wide complex tachycardia with superior axis and RBBB. The baseline was not fibrilliform and AF was not correct. The QRS morphology looked monomorphic, which was against VF. P waves were seen in aVL (after the QRS complexes) and fusion beats could also be seen in leads aVf and II. All these evidences pointed to ventricular tachycardia. This patient suffered from idiopathic left ventricular tachycardia (RBBB and superior axis). In general, no underlying heart disease can be identified and the VT usually responds well to calcium-blockers. It is speculated that the arrhythmia was related to a slowly conducting local re-entry pathway over the postero-apical part of the septum. Radiofrequency ablation achieves an 80% success rate for this kind of arrhythmia.

For this particular patient, the VT was terminated with Isoptin and radiofrequency ablation was done later, which was successful.

 

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Dermatology Series 皮膚科病例研究

A 55 year old Chinese male noticed periungual swelling over his left index finger for over one year. The lesion grew in size slowly and was occasionally tender. There was also deformity over that finger nail. There was no preceding trauma. His general health was good. Physical examination revealed a 5 mm translucent cyst with depression groove over the nail.

The content of the Dermatology Series is provided by:
Dr. Chan Loi Yuen and Dr. Tang Yuk Ming, William
Specialist in Dermatology & Venereology

皮膚科病例研究之內容誠蒙陳來源醫生鄧旭明醫生提供。

Answers

1.

What is the clinical diagnosis?

The clinical diagnosis is digital mucous cyst (or myxoid cyst). They are usually single, asymptomatic, smooth, skin coloured or translucent and contain a clear, viscous, sticky fluid. The size is usually 5-7 mm in diameter. They are most commonly located at the distal interphalangeal joint or in the proximal nail fold. Longitudinal depression over the nail may be present if there is pressure on the nail matrix.

 

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2.

What is the underlying cause?

It is believed to be due to mucoid degeneration of the connective tissue. Osteoarthritis of the adjacent joint is frequently present. There may be connection between the cyst and the adjacent joint. Trauma may also be a causative factor.

 

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3.

How would you confirm the diagnosis?

Transillumination will be helpful in differentiating it from a solid swelling. Aspiration with a needle revealed large amount of clear gelatinous fluid.

 

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4.

What are the investigations?

Ultrasound helps to define whether the structure is cystic or not. MRI is an excellent modality for visualizing soft tissue structure and revealing any communication between the cyst and the joint and is useful pre-operatively.

 

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5.

What are the treatments?

There is no standard optimal treatment approach and recurrence is common. If asymptomatic, no treatment may be required. Treatment modalities include repeated puncture of the cyst by patients; needle aspiration followed by corticosteroid injection; cryotherapy; curettage and cauterization; excision and laser vaporization.

 

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