Online Clinical Case Study (April 2016)

Clinical Cardiology Series

The content of the April Cardiology Series is provided by:
Dr. CHEUNG Ling Ling
MBBS(HK), MRCP(UK), FHKCP, FHKAM(Med), Specialist in Cardiology
Dr. CHUNG Tak Shun
MBBS(HK), MRCP(UK), FHKCP, FHKAM(Med), Specialist in Cardiology

A 46-year-old lady with congestive heart failure

A 46-years-old lady, who enjoyed good past health, presented with ankle edema and mild shortness of breath. She is a non-smoker and non-drinker. She complaint of progressive shortness of breath and ankle swelling for 2 weeks. She also had palpitation for few months.

Her blood pressure was 101/74mmHg and pulse was 198/min on admission. Physical examination showed raised JVP, bilateral lower limb edema up to mid-shin and basal crepitation over bilateral lung base. She had obvious goitre though she denied of any obstructive symptoms. She had exophthalmos, but there was no opthalmoplegia.

Her ECG on admission was shown in Figure 1 and her CXR was shown as Figure 2.

Figure 1

Figure 2

Bedside echocardiogram was performed after admission. Her left ventricular ejection fraction was 30%, there was mild MR and severe TR.

Her relevant blood result was shown in Figure 3.

Figure 3

Cardiac catherterisation was performed and showed normal coronary angiogram.

1. What is shown in Figure 1?
  Atrial fibrillation with rapid ventricular response
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What is shown in Figure 2?

  Cardiomegaly, upper lobe diversion
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3. What are the first line rate control medications for atrial fibrillation with rapid ventricular response?
  Intravenous diltiazem, digoxin, beta blocker
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4. What are the abnormal findings in Figure 3?
  Deranged liver function test, iron deficiency anaemia and hyperthyroidism
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5. What is the likely cause of her heart failure?
  Uncontrolled thyrotoxicosis, tachycardia related cardiomyopathy
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6. What is the CHA2DS2-VASc score for this patient?
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7. Should the patient receive anticoagulation?
  No, CHA2DS2-VASc score of 1 is due to sex risk alone and the unremarkable echo finding put the patient in low risk category, can consider monitor ECG and echo after treatment.
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Dermatology Series 皮膚科病例研究

Dermatology Series for April 2016 is provided by:
Dr. LEUNG Wai Yiu, Dr. TANG Yuk Ming, William, Dr. CHAN Hau Ngai, Kingsley, Dr. KWAN Chi Keung and Dr. CHANG Mee, Mimi
Specialists in Dermatology & Venereology

A middle-aged lady with painful vesicular rash

A middle-aged lady had a three-day history of burning pain on her chest and back and subsequently crops of red papules on anterior chest. Her medical history was positive for diabetes mellitus with associated complications of neuropathy.



1. What is the clinical diagnosis?
The diagnosis is herpes zoster (HZ) or shingles. It usually appears as a stripe of painful vesicles following the dermatome on one side of the body where the chest, forehead, neck, lumbar and sacral spine are more commonly affected. It is also a common disease among elderly and immunosuppressed patients.

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2. What are the differential diagnoses?
It includes cellulitis, acneiform eruptions, insect bites, and irritant contact dermatitis.

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3. What is the cause of this skin condition?

HZ is an infection caused by varicella-zoster virus which lays dominant in the dorsal root throughout the body for years before reactivating as HZ.


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4. What are the common complications?
Postherpetic neuralgia (PHN), a condition of persistent pain which is present for more than a month after the onset of HZ, is common in elderly patients. Facial nerve palsy, ocular complications (in those with HZ ophthalmicus), secondary infection and scarring are the other common complications.

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5. How would you treat this patient?
  There is no cure for HZ and the treatment aims at shortening the duration of infection and relieving the symptoms. Antiviral treatment such as acyclovir and famciclovir are effective treatment of HZ whereas the combined use of systemic steroids in acute phase remains controversial. For PHN, drug categories of NSAIDs, tricyclic antidepressants and anticonvulsants such as gabapentin have been shown effective.
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