Online Clinical Case Study (July 2006)

Clinical Cardiology Series
臨床心臟科個案研究

The content of the Office Cardiology Series is provided by:
Dr. LI Siu Lung, Steven
F.H.K.A.M. (Med), F.R.C.P. (Glasg), F.R.C.P. (Edin), F.R.C.P. (Lond), 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李少隆醫生及王壽鵬醫生提供。

A 65 year old gentleman with known hypertension and recently diagnosed metastatic carcinoma of unknown origin was admitted for progressive shortness of breath for 2 weeks. His blood pressure was 95/56mmHg on admission and his SaO2 was 90%. There was mild ankle swelling. His CXR showed cardiomegaly. This was his ECG on admission.

Answers

1.

What are the major ECG abnormalities?

Tachycardia up to 150/min. Low voltage QRS complexes.
 

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2.

What diagnosis should be suspected from the ECG abnormalities?

Massive pericardial effusion should be suspected. Pericardial effusion causing tamponade effect will cause tachycardia and hypotension. Typically, the ECG will show low voltage QRS complexes and swinging axis of the QRS complexes.
 

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3. What further investigation may confirm the diagnosis?
 

The diagnosis can be easily confirmed by an echocardiogram.
 

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4.

What urgent procedure should be done?
 

Urgent pericardiocentesis to drain out the pericardial fluid and to relieve the tamponade effect should be done immediately. This may either be done by percutaneous or by surgical approach. Due to the hemodynamic instability of this patient, percutaneous drainage was done.
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5.

If the problem recurs, what other treatment may be helpful?
He was found to have pulmonary embolism by CT scan of the thorax and deep vein thrombosis of the lower limbs were confirmed with Doppler study. Anticoagulation with heparin was started. However, his condition was further complicated by gastrointestinal bleeding due to acute bleeding gastric ulcers. Anticoagulation was stopped.

  For recurrent pericardial effusion due to metastatic malignancy, a pericardial window can be made, so that the pericardial effusion would be diverted to the left pleural space for safer and easier drainage. In this patient, this was done via VATS (video assisted thoracic surgery), which is a minimal invasive procedure.
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6.

What other treatment may be offered to minimize the recurrence of pulmonary embolism?
 

An IVC filter may be deployed at the inferior vena cava to prevent any large thrombus to embolize from the lower limbs. In certain situations, the filter may be retrieved a few weeks later when anticoagulation can be restarted again. An IVC filter was deployed in this patient. Note the hook on one end that is used for retrieval.
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Dermatology Series 皮膚科病例研究

A 20 year old Chinese male presented with multiple asymptomatic rough spots on his arms for few years. The rash was more severe during winter. His elder sister also got this condition. Physical examination revealed horny, keratotic follicular papules on the extensor surface of his arms. Some lesions were excoriated and inflammed.

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 diagnosis?

The clinical diagnosis is keratosis pilaris. It is a common condition affecting 50-80% of adolescents and 40% of adults. Positive family history may be present in 30-50% of patients. Females are more commonly affected. There is no increased morbidity or mortality.
 

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2.

Where else will you look for?

Keratosis pilaris most commonly involves the outer aspect of upper arms. It can also affect thighs, forearms, upper back and cheek.
 

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3.

What is the etiology?

It is due to a disorder of corneocyte adhesion that prevents normal desquamation in the area around the follicle.
 

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4.

What are the associating conditions?

Keratosis pilaris is associated with atopic dermatitis and ichthyosis vulgaris. It is more common in those overweight, or have celtic backgrounds.
 

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5.

What is the treatment?

Education and reassurance on the benign nature of this condition is important. Treatment is not required unless it is extensive, symptomatic or cosmetically unacceptable. Measures should be taken to prevent excessive skin dryness. Treatment of non-inflammed lesion includes use of soap-free cleansers, moisturizer, keratolytic agents, topical tretinoin and polyester sponge. However, the response is usually unsatisfactory. This condition tends to improve after a few years. Inflammed lesion requires use of topical steroids.
 

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