Online Clinical Case Study (April 2017)

Clinical Cardiology Series
臨床心臟科個案研究

The content of the April Cardiology Series is provided by:
Dr. CHEUNG Ling Ling
MBBS(HK), MRCP(UK), FHKCP, FHKAM(Med), Specialist in Cardiology
四月臨床心臟科個案研究之內容承蒙張玲玲醫生提供。

Is it anterior ST-elevation myocardial infarction?

Mr. L was a 50 year old gentleman who worked in construction site. He was a non-smoker and non-drinker and enjoyed good past health. He was admitted for recurrent syncope in one morning preceded by some vague left side chest discomfort, nausea and profuse sweating. Each episode lasted for 5-10 mins and he recovered full consciousness afterwards. There was no reported seizure like activity as witnessed by wife. He was haemodynamically stable on arrival to emergency department. There was no focal neurological deficit.

His ECG on arrival was shown below.

Investigations including complete blood picture, liver renal function test and cardiac enzyme were all normal. CT brain was unremarkable as well. Coronary angiogram was also normal on the day after admission.

1. What is your ECG diagnosis?
a) Anterior ST elevation myocardial infarction
b) Normal variant
c) Right bundle branch block
d) Wellens syndrome
e) Brugada syndrome
  Brugada syndrome
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2.

In making the diagnosis in 1), what other criteria you need beside ECG abnormality?
a) Documented ventricular fibrillation (VF) or polymorphic ventricular tachycardia (VT)
b) Family history of sudden cardiac death at <45 years old
c) Cove-type ECGs in family members
d) Inducibility of VT with programmed electrical stimulation
e) Syncope
f) Nocturnal agonal respiration
g) All of the above

  All
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3.

Which type of the diagnosis?
a) Type 1
b) Type 2
c) Type 3

  Type 1
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4.

What is the definitive management of the condition?
a) Implantable cardioverter defibrillator
b) Electrophysiological study
c) Class 1 antiarrhythmic drugs

  Implantable cardioverter defibrillator
Decision making in Brugada ECG pattern:
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5.

What is the mortality per year of the condition without intervention?
a) 5%
b) 10%
c) 15%

  10%
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Reference:
Antzelevitch C, Brugada P, Borggrefe M et al. Brugada Syndrome: Report of the Second Consensus Conference: Endorsed by the Heart Rhythm Society and the European Heart Rhythm Association. Circulation 2005 February 8;111(5):659-70.

   
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Dermatology Series 皮膚科病例研究

Dermatology Series for April 2017 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
四月皮膚科個案研究之內容承蒙張苗醫生鄧旭明醫生陳厚毅醫生關志強醫生梁偉耀醫生提供。

Facial rash on a young gentleman

A 35-year-old man presented with persistent redness of the cheeks and forehead for 3 weeks. He was suddenly noted to be sensitive to sunlight with burning sensation. The redness was not preceded by intake of alcohol or spices. He did not have topical contactant on the face and did not take any new medications. There was no history of atopy. He also had low grade fever, oral ulcers and pain of the small hand joints.

Answers

1. What is the diagnosis?
Malar erythema of acute cutaneous lupus erythematosus. It is the prototype of acute cutaneous lupus and is characterized by photosensitivity, confluent erythema on malar areas in a butterfly distribution while sparing the nasolabial folds. It can last for weeks, and can occur on other photo-exposed areas, including the forehead, chin, upper and back of neck and dorsum of hand (interphalangeal part). It is typically non-scarring, and is highly associated with systemic lupus erythematosus (SLE) in conjunction with other cutaneous and extra-cutaneous symptoms. The patient was subsequently diagnosed to have SLE with hematological, joint and skin involvement.
 

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2. What are the differential diagnoses?
Rosacea, seborrheic dermatitis, contact dermatitis, polymorphic light eruption and dermatomyositis.
 

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3. What tests should be ordered?
Extensive history taking and physical examination for other autoimmune symptoms and baseline blood tests with CBC LRFT, ANA, C3, C4, anti-DsDNA, CK and urinalysis should be undertaken. Skin biopsy (interface dermatitis) is usually not necessary for classical malar erythema. Early referral to rheumatology is needed if SLE is confirmed.
 

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4. What are the possible treatment options?
General measures to rest and avoidance of ultraviolet exposure is important. Treatment of SLE will render the resolution of malar erythema. Topical steroid or hydroxychloroquine are useful adjunct to treatment of SLE.
 

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