Online Clinical Case Study (February 2009)

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 FHKAM (Med), FRCP (Glasg), FRCP (Edin), FRCP (Lond),
Specialist in Cardiology,
Dr. WONG Shou Pang, Alexander FRCP, FHKAM (Med.), FHKCP,
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 63-year-old gentleman with a history of coronary artery bypass graft (CABG) surgery

A 63-year-old gentleman who underwent CABG 8 years ago is scheduled for an inguinal hernia repair. He has diabetes, hypertension and hypercholesterolaemia. He has no chest pain or symptoms of heart failure. He can play a full 18-hole golf game by walking without any symptoms. He is now taking aspirin, statin, ACEI and beta-blockers. Physical examination showed normal blood pressure with no signs of heart failure. His renal function is normal.

Answers

1.

How many clinical cardiac risk factors does this patient have?
a. 1
b. 2
c. 3
d. 4
  b. According to the Revised Cardiac Risk Index in the American College of Cardiology (ACC)/American Heart Association (AHA) guideline, he has two risk factors: ischaemic heart disease and diabetes.
   
2.

Is any additional cardiac test is needed for this patient?
a. Yes
b. No
 

b. No.
   
3.

Which of the following therapies are indicated for this patient? It may be one or more therapies.
a. Continue beta-blocker
b. Continue statin
c. Intra-operative nitrates
d. a and b
e. b and c
 

d. A and B.
Pre-operative assessment for cardiac patients undergoing non-cardiac surgery is a common clinical task for every physician. The ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery gives very concise and practical recommendations for clinicians.

A detailed history taking and physical examination is of the utmost importance. An ECG within 30 days would be useful except in an asymptomatic patient undergoing low risk surgery. Active cardiac conditions should be excluded: unstable coronary syndrome, decompensated heart failure, significant arrhythmias and severe valvular heart disease. All active cardiac conditions needed to be treated before the operation unless the non-cardiac surgery is urgent and life-saving.

For those without an active cardiac condition, assessment should be made on functional status, symptoms, number of cardiac risk factors and type of non-cardiac surgery. Cardiac risk factors include ischaemic heart disease, congestive heart failure, cerebrovascular disease, diabetes mellitus, renal insufficiency and high-risk surgery. Aortic and major vascular surgery are high risk (>5%). Intermediaterisk surgery (1–5%) includes intrathoracic and intraperitoneal surgery, prostate surgery, orthopaedic surgery, carotid enarterectomy, and endovascular aortic procedures. Low-risk surgery (<1%) includes superficial procedures, cataract surgery, breast surgery and ambulatory procedures.

For low-risk surgery in asymptomatic patients, no further cardiac test is needed pre-operatively. If a patient is symptomatic or unable to exercise at 4 METs, the need for additional testing depends on the number of cardiac risk factors and the risk of surgery involved. If there is no cardiac risk factor, one may proceed directly to surgery. If there are only 1–2 risk factors, further tests are optional. If there are 3 or more factors, further tests such as the stress test are recommended for vascular surgery, and are optional for intermediate surgery.

In patients with known coronary artery disease, if haemodynamically tolerated, beta-blockade therapy to control heart rate <65/min is generally recommended. Similarly, statin therapy is also considered useful before surgery.

In all patients, close post-operative monitoring is essential to identify any post-operative complications promptly.
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Dermatology Series 皮膚科病例研究

A 40-year-old male with fingernail dystrophy

A 40-year-old cook presented with finger nail dystrophy for one year. He complained that his finger nails had became soft, easily breakable and did not grow. There was no systemic symptom. His past health was good with no history of long-term medication. He worried about fungal infection. Physical examination revealed horizontal splits of his distal finger nails.
Dr. CHAN Loi-yuen, Dr. TANG Yuk-ming, William,
Dr. MAK Kam-har & Dr. CHAN Hau-ngai, Kingsley.
Specialists 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、麥錦霞醫生及陳厚毅醫生提供。

Answers

1.

Does he have onychomycosis?
No. The clinical features of onychomycosis such as onycholysis, subungual hyperkeratosis and discolouration of the nail plates are not present in this patient.
 

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2.

What is the diagnosis?
The diagnosis is onychoschizia, also known as lamellar splitting.
 

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3.

What is the pathogenesis?
It is due to breakage of the intercellular corneocyte bridges of the nails resulting in fragile and brittle nails.
 

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4.

What are the possible underlying causes?

Frequent wetting of the nail is the most frequently implicated cause for this condition. Other causes include contact with detergents and dehydrating chemicals, old age and polycythemia vera. The condition may also be associated with psoriasis, lichen planus, systemic retinoid therapy or it may be inherited (X-linked).
 

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5.

What are the treatments?
Treatment is often difficult. Possible exogenous factors should be avoided. Patients should avoid frequent contact with water or irritants, including nail polish. The nails should be kept appropriately hydrated with moisturizers containing alpha-hydroxy acid or phospholipids. Biotin has been reported to be useful in some patients suffering from this condition.
 

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