Online
Clinical Case Study (March
2006)
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.B.,B.S.(H.K.), M.R.C.P.(Ireland), M.R.C.P.(U.K.), F.H.K.C.P.,
F.H.K.A.M. (Med), 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
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、李少隆醫生及
王壽鵬醫生提供。
An 81 year old lady
was admitted through the emergency department for palpitation since this morning.
She was fully ambulatory and was asymptomatic apart from the palpitation. Blood
pressure was 140 / 80 and her pulse rate was 140/min. Her oximetry saturation
was 99%. Urgent electrolytes and cardiac enzyme were normal. Her ECG was shown
below
Answers
| 1. |
What is your most likely diagnosis?
a) Wolf Parkison White Syndrome
b) SVT with aberrancy
c) Ventricular Tachycardia
d) Torsades De Pointes
e) Ventricular Fibrillation
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c.
This was a wide complex
tachycardia. The chest leads showed that it was a RBBB pattern with positive
concordance. There was AV dissociation and fusion beats were seen in lead
II. The diagnosis was ventricular tachycardia and the QRS complexes were
of similar shape i.e. monomorphic. The origin of the VT was most likely
from the left ventricle (RBBB pattern) with a superior origin (deep S
in inferior leads).
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| 2. |
What
is your initial management?
a) IV amiodarone
b) IV procainamide
c) Cardioversion
d) Carotid massage
e) IV ATP
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a.
If the patient is hemodynamically stable, pharmacological conversion with
IV amiodarone/ lignocaine may be attempted. Second line agents include
procainamide. If medical treatment failed, synchronized cardioversion
would be needed. Overdrive pacing should be considered if repeated cardioversion
is needed.
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| 3. |
What
is your future plan?
a) Oral anti-arrhythmic drugs such as amiodarone
b) Coronary angiogram plus angioplasty
c) ICD implantation
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c.
This patient had a ventricular arrhythmic event. According to the SCD-Heft
trial and Madit II trial, an ICD implantation prevents more sudden cardiac
death than anti-arrhythmic drugs such as amiodarone, which is no better
than placebo. Coronary angiogram is needed to rule out coronary stenosis
but even successful revascularization may not prevent sudden arrhythmic
death since the patient did not show any acute ischemic culprit for her
VT. Indeed, the echocardiogram of this lady showed dilated cardiomyopathy
with a left ventricular ejection fraction of only15 %.
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Dermatology
Series 皮膚科病例研究
A 35 year old lady
presented with an asymptomatic linear brownish discoloration over her left index
finger nail for one year and recently noted slight accentuation of the colour.
She recalled no recent drug intake and there was no history of trauma. Her general
health was good. Physical examination showed a brownish longitudinal subungual
streak measuring 1 mm width. The nail texture was unremarkable. Other nails
were normal.
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The
content of the Dermatology Series is provided by:
Dr. CHAN Loi Yuen, Dr. KU Lap Shing, Simon & 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、顧立誠醫生及鄧旭明醫生提供。 |
Answers
| 1. |
What
is the clinical description for the abnormality?
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It is a longitudinal
melanonychia.
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| 2. |
What
are the differential diagnoses?
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The differential
diagnoses include melanosis or melanocytic naevus of the nail matrix,
or rarely a malignant melanoma.
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| 3. |
What
are the possible causes?
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It may be
a normal finding and found on several digits in Black patients. It has
been reported in 77- 96% of Blacks and 11% of Asians. It may be caused
by systemic diseases (such as Addison’s disease, Peutz-Jeghers syndrome,
acanthosis nigricans, vitamin B12 deficiency), drug (such as chemotherapy,
antimalarials, and minocycline), after trauma or photochemotherapy and,
post-inflammatory events (after lichen planus or fixed drug eruption).
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| 4. |
What
are the clinical signs suggestive of a more significant problem?
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The signs
indicative of an underlying subungual melanoma include: periungual spread
of the pigment (Hutchinson’s sign), darkening of an established band,
progressive widening of the linear streak with blurring of its border,
single nail involvement, and patient’s age over 50 years.
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| 5. |
What
is the management?
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A biopsy
of the lesion over the nail matrix and nail bed should be performed if
there is clinical suspicion of malignancies.
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