Online Clinical Case Study (November 2015)

Clinical Cardiology Series
臨床心臟科個案研究

The content of the November Cardiology Series is provided by:
Dr. WU Kwok Leung
MBBS(HK), MRCP(UK), FHKCP, FHKAM(Med), Specialist in Cardiology
十一月臨床心臟科個案研究之內容承蒙胡國樑醫生提供。

A lady presented with pulseless electrical activity

A 66-year-old lady who had past medical history of diabetes mellitus was admitted for progressive shortness of breath. The attached electrocardiogram was the one performed in the casualty department. She lapsed into pulseless electrical activity soon after admission. Cardiopulmonary resuscitation was commenced.

1. What is the diagnosis based on the ECG features and the clinical profile?
A. Sinus tachycardia.
B. Non-ST segment elevation myocardial infarction.
C. Pulmonary embolism.
D. ST-segment elevation myocardial infarction.
E. Unstable angina.
  C
  Back to top
   
2.

Which of the following is not a typical feature of this disease entity?
A. Sinus Tachycardia.
B. Left axis deviation.
C. P pulmonale (> 2.5mm in inferior leads).
D. S1QIIITIII.
E. Diffuse ST depression and T wave inversion over precordial leads.

  B
  Back to top
   
3. Which treatment is not recommended in the acute phase?
A. Intravenous morphine for pain control.
B. Low molecular weight heparin.
C. Intravenous magnesium sulfate.
D. Intravenous thrombolytic therapy if failed anticoagulation therapy.
E. Oxygen therapy.
  C
  Back to top
   
4. Which is not a risk factor of this disease entity?
A. Obesity.
B. Recent febrile illness.
C. Recent immobilization.
D. Oral contraceptive pills.
E. Family history of thrombophilia.
  B
  Back to top
 

 

 

Discussion:

The initial electrocardiogram showed sinus tachycardia. Moreover, right axis deviation, Q wave formation and T wave inversion over limb lead III (S1QIIITIII) were detected. Therefore the diagnosis was pulmonary embolism leading to pulseless electrical activity. Subsequently this patient failed cardiopulmonary resuscitation and she succumbed. Other features of pulmonary embolism include P pulmonale, diffuse ST segment depression as well as T wave inversion over precordial leads. Left axis deviation on electrocardiogram was not a feature of pulmonary embolism.

In the acute phase, low molecular weight therapy is the mainstay of treatment for pulmonary embolism (1). Other supportive treatments may be required which include oxygen therapy and intravenous morphine for pain control. Massive pulmonary embolism leading to hemodynamic instability is an indication for intravenous thrombolytic therapy (2).

Risk factors of pulmonary embolism can be classified according to the Virchow's triad (alterations in blood flow, trauma to the vessel wall and pro-coagulant state).

  1. Alterations in blood flow: immobilization (after surgery, injury, pregnancy), obesity, cancer.
  2. Trauma to the vessel wall: trauma, surgery.
  3. Pro-coagulant state:
    • Estrogen-containing hormonal contraception
    • Genetic thrombophilia
    • Acquired thrombophilia (e.g. antiphospholipid syndrome)
    • Malignancy

References:

  1. Erkens PM, Prins MH, Martin H, ed. “Fixed dose subcutaneous low molecular weight heparins versus adjusted dose unfractionated heparin for venous thromboembolism”. Cochrane Database Syst Rev (9): CD001100. 8th Sept 2010.
  2. Konstantinides, SV; Torbicki, A; Agnelli, G; Danchin, N; Fitzmaurice, D; Galie, N; Gibbs, JS; Huisman, MV; Humbert, M; Kucher, N; Lang, I; Lankeit, M; Lekakis, J; Maack, C; Mayer, E; Meneveau, N; Perrier, A; Pruszczyk, P; Rasmussen, LH; Schindler, TH; Svitil, P; Vonk Noordegraaf, A; Zamorano, JL; Zompatori, M; 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism. 29th August 2014.
   
  Back to top

Dermatology Series 皮膚科病例研究

Dermatology Series for November 2015
Dr. LEUNG Wai Yiu, Dr. TANG Yuk Ming, William, Dr. CHAN Hau Ngai, Kingsley, and Dr. KWAN Chi Keung
Specialists in Dermatology & Venereology
十一月皮膚科個案研究之內容承蒙梁偉耀醫生鄧旭明醫生陳厚毅醫生關志強醫生提供。

A lady with itchy skin for three years

A 34-year-old lady presented with a three-year history of itchy skin over right foot. This lesion waxed and waned and became aggravated during climate changes. The patient enjoyed a good past health. She had no ongoing medication taken or any relevant family history of similar lesion. Physical examinations showed erythematous thickened scaly plaques on her right foot. There were no other skin manifestations of psoriasis or contact dermatitis nor fungal infection.

Answers

1. What are the differential diagnoses?
The differential diagnoses include psoriasis, epidermal nevus, lichen planus, tinea pedis and irritant contact dermatitis.
 

Back to top

 

2. What is the diagnosis?
The clinical diagnosis is Lichen simplex chronicus (LSC). The exact mechanism is unknown and is believed to be from repetitive scratching and rubbing. It is more commonly found in middle-aged group, female and those with anxiety or compulsive disorder. Neck, ankles, wrist and genitalia are the commonly involved sites.
 

Back to top

 

3. How do you confirm the diagnosis?
It is a clinical diagnosis and skin biopsy is rarely necessary unless in doubtful cases such as psoriasis or epidermal nevus. Skin scrapings may sometimes be needed for suspected fungal infection.
 

Back to top

 

4. What are the associated skin diseases and relevant investigations?
As LSC is not a primary process, a search for underlying primary dermatosis should therefore be carried out. The common primary causes include atopic dermatitis, contact dermatitis, psoriasis, fungal infection and lichen planus etc. Relevant investigations should be guided by the appropriate physical examination which point to specific underlying disease.
 

Back to top

 

5. What are the treatments?
  Treatment includes symptomatic control of LSC and that of the underlying primary cause. Topical corticosteroids, oral antihistamines and frequent use of moisturizers remain the main symptomatic treatment for LSC to control the Itch-Scratch cycle. Topical potent corticosteroids under occlusion and intralesional steroid injection were shown to be effective in refractory cases, whereas the treatment of the underlying disease was directed by the relevant causation.
  Back to top

Back to Online Clinical Case Study