Online Clinical Case Study (November 2017)

Clinical Cardiology Series
臨床心臟科個案研究

The content of the November Cardiology Series is provided by:
Dr. TAN GuangMing
MBChB, MRCP, FHKCP, FHKAM (Med), Specialist in Cardiology
Dr. CHEUNG Shing Him, Gary
MBBS, MRCP, FHKCP, FHKAM (Med), Specialist in Cardiology
十一月臨床心臟科個案研究之內容承蒙譚廣明醫生張誠謙醫生提供。

CASE 1 - A young patient with abdominal pain and weight loss

A 34-year-old gentleman with good past health presented for 1 year onset of progressive abdominal pain. The pain localized at the epigastrium. There was positional change of pain severity especially when he was lying on his left side. Other than that, there was no other relieving or aggravating factors of the pain. He also complained of loss of appetite and progressive weight loss of > 20lb in the past year. He had been a cyclist and regular jogger, but he noted a marked progressive decrease of his exercise tolerance.

Physical examination was essentially unremarkable. Notably there was no abdominal bruit on auscultation when patient is in supine position.

Extensive investigations including upper and lower endoscopy, CT and MRI abdomen with contrast could not identify a cause for his symptoms. A Duplex ultrasound of the mesenteric vessels were performed. Selected images are shown below.


Figure 1. Abdominal Aorta Spectral Doppler


Figure 2. Celia Artery Spectral Doppler during Inspiration and Expiration


Figure 3. SMA and IMA Spectral Doppler

Answer Sheet

Complete Cardiology CASE 1, 0.5 CME POINT will be awarded for at least 2 correct answers in total

Clinical Cardiology Series臨床心臟科個案研究

1. What did the Duplex ultrasound demonstrate?
A. Celiac Artery stenosis
B. Aortic stenosis
C. Superior Mesenteric Artery stenosis
D. Inferior Mesenteric Artery stenosis
E. Dynamic compression of the celiac artery

2. What is your diagnosis?
A. Chronic mesenteric ischemia
B. Heyde's syndrome
C. Anorexia Nervosa
D. Chronic pancreatitis
E. Median Arcuate Ligament Syndrome (MALS)

3. What are the treatment options?
A. Medical treatment with antacid
B. percutaneous angioplasty
C. Decompression of the celiac artery
D. Neurolysis of celiac plexus
E. The combination of both C & D


The content of the November Cardiology Series is provided by:
Dr. WONG Chi Yuen
MBBS (HK), MRCP (UK), FHKCP, FHKAM (Medicine), Specialist in Cardiology
Dr. CHUI Shing Fung
MBChB (CUHK), MRCP (UK), FHKCP, FHKAM (Medicine), Specialist in Cardiology
十一月臨床心臟科個案研究之內容承蒙黃志遠醫生徐城烽醫生提供。

CASE 2 - An 84-year-old gentleman with exertional chest pain and shortness of breath

An 84-year-old gentleman, independent of daily living, with known history of diabetes mellitus, hypertension and peripheral vascular disease, presented with exertional chest pain and shortness of breath in recent few months. Physical examination revealed loud ejection systolic murmur best heard over right upper sternal border of 2nd intercostal space with radiation to the neck.

Answer Sheet

Complete Cardiology CASE 2, 0.5 CME POINT will be awarded for at least 2 correct answers in total

Clinical Cardiology Series臨床心臟科個案研究

1. What investigation(s) would be helpful in this case?

1. ECG
2. Chest X-ray
3. Echocardiogram
4. Treadmill exercise stress test

A. 1 and 4
B. 2 and 4
C. 3 and 4
D. 1, 2 and 4
E. All except 4

ECG was performed and showed sinus rhythm with left ventricular hypertrophy (Figure 1). Echocardiogram revealed satisfactory left ventricular systolic function, the aortic valve was calcified and thickened with severe aortic stenosis, the mean gradient across aortic valve was 46mmHg (Figure 2 and 3).


Figure 1


Figure 2


Figure 3

2. Which of the following medication should be avoided?
A. Aspirin
B. Metoprolol
C. Frusemide
D. TNG
E. Panadol

3. Which of the following is/are the appropriate DEFINITIVE treatment of this patient?

1. Conservative management
2. Balloon Aortic Valvuloplasty
3. Open surgical aortic valve replacement
4. Transcatheter aortic valve implantation (TAVI)

A. 1
B. 2
C. 1 and 2
D. 3 or 4


Dermatology Series 皮膚科病例研究

Dermatology Series for November 2017 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
十一月皮膚科個案研究之內容承蒙關志強醫生鄧旭明醫生陳厚毅醫生梁偉耀醫生張苗醫生提供。

CASE 1 - Nodules on the lip

A 88 year-old fisherman complained of a few nodules on his lower lip for nearly 4 years. The nodules were asymptomatic but increasing in size very slowly. There was no trauma history and no spontaneous bleeding. The largest one was around 1.0 cm in diameter which was deep blue in colour. It was not tender. The surface was smooth. There was no abnormality detected in the oral cavity.

Answer Sheet

Complete Dermatology CASE 1, 0.5 CME POINT will be awarded for at least 3 correct answers in total

Dermatology Series 皮膚科病例研究

1. What is your diagnosis?
a) Basal cell carcinoma
b) Squamous cell carcinoma
c) Benign Melanocytic Naevus
d) Venous Lakes
e) Melanoma

2. Helix of ear is also the common area for this lesion. (True or False)

3. Long term sun exposure is one of the precipitating factors for this lesion. (True or False)

4. What investigation can help you to make the diagnosis?
a) No investigation is needed for diagnosis
b) Diascopy
c) Dermoscope
d) Skin biopsy
e) All of the above

5. Incisional and Drainage (I & D) is the best treatment for this gentleman. (True or False)


Dermatology Series for November 2017 is provided by:
Dr. CHANG Mee, Mimi, Dr. TANG Yuk Ming, William, Dr. CHAN Hau Ngai, Kingsley, Dr. LEUNG Wai Yiu and Dr. KWAN Chi Keung
Specialists in Dermatology & Venereology
十一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梁偉耀醫生關志強醫生提供。

CASE 2 - A 50 year-old man with painful skin rash

A 50 year-old man, who newly started allopurinol for 2 weeks for gouty attack, was admitted for generalized painful skin rash (> 50% body surface area) and flaccid blisters involving his face, body and limbs for 3 days. There were also oral and genital erosions. He was febrile, and with a blood pressure of 120/80 and pulse 120. His baseline bloods were normal. He enjoyed good past health.

Answer Sheet

Complete Dermatology CASE 2, 0.5 CME POINT will be awarded for at least 2 correct answers in total

Dermatology Series 皮膚科病例研究

1. What is the most likely diagnosis?
a. Stevens Johnson syndrome
b. Toxic epidermal necrolysis
c. Acute generalized exanthematous pustulosis
d. Pemphigus vulgaris
e. Infective exanthem

2. What is the most common cause of the problem?
a. Idiopathic
b. Viral infections
c. Drug
d. HIV seroconversion
e. Autoantibodies targeted at the hemidesmosomes of the epidermal keratinocytes

3. Which type of HLA allele test could be ordered to predict the increased individual risk of Stevens Johnson Syndrome and Toxic Epidermal Necrolysis in allopurinol use?
a.HLA-B*5801
b.HLA-B*5701
c.HLA-A*3101
d.HLA-B*1502
e.HLA-B*1301

4. What is the best course of management?

i. The patient should be given best supportive medical treatment
ii. Allopurinol should be stopped immediately
iii. Intravenous immunoglobulin is the first-line treatment with strongest evidence with survival benefit
iv. Ophthalmologist should be consulted to look for eye involvement
v. Active debridement of skin is important to reduce risk of infection

A. i and ii
B. i, ii and iv
C. ii, iii, and v
D. i, ii, iii and iv
E. all of the above

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