Online Clinical Case Study (September 2010)

Clinical Cardiology Series

A 78-year-old lady admitted for dizziness

A 78-year-old lady was admitted for dizziness. She has had good past health and is not on any medications. She has no history of syncope, but in the past few days she experienced dizziness with a decrease in exercise capacity. Her ECG is shown in Figure 1.

Figure 1. ECG on admission.



What is the diagnosis?
a. First-degree heart block
b. Second-degree heart block
c. Complete heart block
d. Sinus arrhythmia

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What treatment does she need?
a. Beta blockers
b. No treatment is needed
c. Pacemaker implantation

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According to the American College of Cardiology/American Heart Association/Heart Rhythm Society (ACC/AHA/HRS) Guidelines for device-based therapy 2008, permanent pacemaker implantation is indicated for advanced second-degree AV block at any anatomic level when associated with: 1. bradycardia with symptoms; 2. arrhythmias and other medical conditions requiring drug therapy that results in symptomatic bradycardia; 3. documented periods of asystole .3 seconds, or any escape rate <40 bpm, or with an escape rhythm that is below the AV node; 4. atrial fibrillation and bradycardia with one or more pauses of at least 5 seconds or longer; 5. post-catheter ablation of the AV junction; 6. postoperative AV block that is not expected to resolve after cardiac surgery; 7. neuromuscular diseases with AV block; 8. second-degree AV block with symptomatic bradycardia, regardless of type or site of block; or 9. exercise-induced second- or thirddegree AV block during exercise in the absence of myocardial ischaemia.

This lady fulfills the criteria of points 3 and 8, and pacemaker implantation is indicated. There are different types of pacemakers, such as single or dual chambers, with or without rate responsiveness functions. One algorithm is shown in the Figure.

Suggested reading

ACC/AHA/HRS 2008 Guidelines for Device-based Therapy of Cardiac Rhythm Abnormalities. Circulation 2008;117:2820–40.

Figure. Algorithm from the ACC/AHA/HRS Guidelines 2008.



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Dermatology Series 皮膚科病例研究

A 32-year-old male with a progressive rash on his body

A 32-year-old male presented with a progressive rash on his body that had been present for three weeks. The rash was mildly itchy. A single larger patch of rash appeared on his lower back about one week before the more generalized eruption (Figure 1). It was not accompanied by fever or any systemic upsets, and there was no history of intake of medicine before its onset. Physical examination showed multiple oval-shaped, erythematous patches with collarette scales scattered along the lines of cleavage on the trunk (Figure 2), and on the proximal part of his arms and thighs. There was no palmoplantar or facial involvement.

Figure 1. The single scaly erythematous patch on his lower back which appeared one week before generalized eruption of other lesions.

Figure 2. The eruption on the trunk.

The content of the Dermatology Series is provided by:
Dr. MAK Kam Har, Dr. TANG Yuk-ming, William, Dr. CHAN Loi-yuen,
Dr. CHAN Hau-ngai, Kingsley & Dr. CHAN Yiu-hoi



What are the diagnosis and differential diagnoses?

The clinical diagnosis is pityriasis rosea (PR). The differential diagnoses include drug eruption (e.g. captopril, barbiturates), secondary syphilis, guttate psoriasis and tinea corporis.

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What is the specific term for the single patch of rash which precedes the generalized secondary eruption?

Herald patch. It appears in around 80% of cases.

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Please describe the so-called collarette scale and the characteristic pattern of the eruption?

Collarette describes a scale that is attached at the periphery and loose toward the centre of the lesion. In classical cases, the long axis of exanthematous lesions follows the lines of cleavage in a “Christmas tree” distribution. The eruption is usually confined to the trunk and proximal parts of the limbs.

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What is the aetiology of this skin disorder?

The aetiology of PR remains unclear. Although an infectious aetiology (human herpesvirus 6 & 7) has been suggested, PR is considered non-infectious

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What is the course of the disease and the management?

The disease is self-limiting, and spontaneous remission occurs in 6–12 weeks. If the eruption persists, a skin biopsy should be done. Oral antihistamines and mild to moderately potent topical steroids are the symptomatic treatment options. Phototherapy may be considered in severe cases.

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