Online Clinical Case Study (July 2016)

Clinical Cardiology Series

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

A 43-year-old gentleman with chest pain and presyncope

Mr. L, a 43-year-old engineer, was a chronic smoker who had past history of asthma followed up by private family doctor. He was admitted to hospital for acute onset of chest pain and presyncope in March, 2016. He was in cardiogenic shock at AED. The ECG on admission was shown in figure 1. He was given TNG spray, aspirin 300mg and atropine 0.6mg for 2 doses, the ECG afterwards was shown in figure 2.

He was diagnosed to have acute inferior ST- elevation myocardial infarction and was planned for primary percutaneous coronary intervention. His coronary angiogram was shown in figure 3. Intracoronary medication was given and the result was shown in figure 4.

Figure 1

Figure 2

Figure 3

Figure 4

1. What is shown in figure 1?
  Complete heart block, ST-elevation in inferior leads
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What is shown in figure 3?

  Right coronary artery spasm, temporary pacing wire in right ventricle
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Name 3 medications for relieving the condition in figure 3.

  Sodium nitroprusside, verapamil, nitroglycerin
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4. Name 3 medications known to associate with the condition in figure 3.
  Ephedrine, antimigraine, cocaine
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Dermatology Series 皮膚科病例研究

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

A Greenish Nail

A 50 year-old man who works as a cook complained a greenish discolouration of his right thumb nail. He could not call any history of trauma. There was no pain and discomfort. Physical examination reviewed a greenish patch under the right thumb nail plate with mild onycholysis.



1. What are the differential diagnoses?
The differential diagnoses include tinea infection of nails, melanonychia, melanoma, chloronychia, trauma to nail plate, onycholysis and so on.

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2. What is the diagnosis?
The diagnosis is chloronychia or green nail syndrome.

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3. What is the likely cause?
The chloronychia or green nail syndrome is caused by bacteria called pseudomonas aeruginosa. It produces characteristic green pigments called pyocyanin and pyoverdin.

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4. What are the precipitating factors?
There are few precipitating factors. The first is onycholysis. When the nail plate is lifted off abnormally, this may create a subungunal space for the entry of pseudomonas aeruginosa. So people working as gardeners, carpenters or plumbers who are easier to have trauma on the nail plate contributing to onycholysis are at higher risk. Secondly, nails repeated immersed in water like dishwashers, housewives, cooks and health care workers may also have higher risk for pseudomonas aeruginosa infection. Prolonged wearing of tight-fitting shoes such as in military recruits or soccer players are also at risk. Finally, psoriatic nails or onychomycosis may occasionally precipitate pseudomonas infection in the nail.

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5. What is the treatment?
General measures such as cutting the detected portion of the nail, keeping the nail dry and avoiding trauma to nail plate are essential. Topical antibiotics such as polymyxin B and bacitracin may be useful. In severe cases, oral quinolone such as ciprofloxacin may be needed.

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