Online Clinical Case Study (October 2016)

Clinical Cardiology Series

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

A 62 year old gentleman with chest pain

Mr. M was a 62 year old gentleman. He had past history of dilated cardiomyopathy and atrial fibrillation. He was put on warfarin and was followed up in the cardiac clinic. Mr. M attended emergency department due to sudden onset of precordial chest pain after bath at 7 o'clock in the afternoon. There was associated dull back pain. He was conscious but was in profound distress. His blood pressure was 70/30. His ECG was shown in Figure 1 and CXR in Figure 2. The cardiologist on call was informed to assess the patient for suspected acute coronary syndrome. Echo was performed and shown in Figure 3.

Figure 1

Figure 2

Figure 3a. Parasternal long axis view

Figure 3b. Suprasternal short axis view

1. What is shown in Figure 2?
  Widened mediastinum
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What is shown in Figure 3?

  Dissection flap
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What is your next investigation after Figure 3?

  Urgent CT thorax with contrast
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4 What is your management for condition shown in Figure 3?
  Stabilise haemodynamic and urgent consult cardiothoracic surgeon
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Dermatology Series 皮膚科病例研究

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

A 60-year-old lady with facial acne, painful pustules and nodules


A 60-year-old lady presented with long standing history of facial acne, painful pustules and nodules on axilla and groin for 20 years. She had history of hypertension, diabetes and obesity. There were no systemic symptoms. She was given prolonged course of antibiotics and topical antiseptics with poor response and was once treated surgically for infected cyst on thigh.


1. What is the diagnosis?
Hidradenitis suppurativa (HS). Inflammed papulonodules, scarring and sinus tracts were found in axilla. Other skin changes of obesity (skin tags and acanthosis nigricans) were shown.

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2. What are the differential diagnoses?
Acne conglobata, carbuncles, multiple epidermoid cysts, fistulating infections (scrofuloderma, mycetoma, granuloma inguinale) and fistulating Crohn's disease.

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3. What is the pathophysiology and what tests can be done?
HS is a suppurative scarring disease of the apocrine glands. Affecting the female population more commonly, HS is a chronic condition characterized by recurrent painful boils, inflammatory papulonodules,sterile abscesses and draining sinus tracts, in the axillae, groin, perianal and inframammary areas. Chronic ulceration and scarring can be complicated by squamous cell carcinoma and secondary amyloidosis. Patients may also suffer from malodour and recurrent infections. There is no specific test for the diagnosis. Initial wound swab for bacteriology can be negative. Later, the lesions could be secondarily colonized by skin flora or other bacteria leading to infections. Skin biopsy is seldomly performed for diagnosis but it may show keratin occlusion of apocrine duct and hair follicle, inflammation and subsequent fibrosis and scarring of the apocrine and pilosebaceous unit.

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4. What are the possible treatment options?
General measures to encourage weight reduction, smoking cessation, reduction of friction and moisture in intetriginous areas are important (antiseptics, aluminium chloride). Mild disease can be treated with tetracycline group of antibiotics for its anti-inflammatory effect, and intralesional steroid for individual inflamed lesions. Further treatment for severe disease includes systemic retinoids, cyclosporine, or TNF-alpha antagonists. Scarring and sinus tracts can be managed by wide local excisions and secondary intention healing.

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