Online Clinical Case Study (December 2017)

Clinical Cardiology Series
臨床心臟科個案研究

The content of the December Cardiology Series is provided by:
Dr. CHEUNG Ling Ling
MBBS(HK), MRCP(UK), FHKCP, FHKAM(Med), Specialist in Cardiology
十二月臨床心臟科個案研究之內容承蒙張玲玲醫生提供。

A 57 year old gentleman with refractory hypertension

Mr. Y was a 57 year old minibus driver. He was a chronic smoker. He had past history of metabolic syndrome (Diabetes mellitus, hypertension, hypertriglyceridemia and obesity). Sleep study confirmed moderate obstructive sleep apnea and was put on CPAP machine. His current medications included the following:

Aspirin tablet oral: 80 mg daily
Carvedilol tablet oral: 12.5 mg BD
Gemfibrozil (LOPID) tablet oral: 600 mg BD
Gliclazide (DIAMICRON) tablet oral: 40 mg BD
Hydralazine HCl tablet oral: 100 mg Q8H
Hydrochlorothiazide tablet oral: 50 mg daily
Nifedipine (ADALAT RETARD) sustained release tablet
oral: 40 mg Q8H
Pantoprazole Sodium Sesquihydrate (PANTOLOC) tablet
oral: 40 mg daily
Prazosin HCl (MINIPRESS) tablet oral: 4 mg TDS

He attended AED due to dizziness and his blood pressure upon admission was 240/120. His ECG, CXR and relevant blood result were shown below:

In view of the renal deterioration, USG kidney was done which showed right renal length of 14.4cm and left renal length of 12.3cm, there were multiple renal cysts measuring up to 4.9cm.

Contrast CT abdomen was therefore ordered.

1.

What will you do if you were the AED medical officer?
a) Step up anti hypertensives and discharge the patient
b) Consult CCU/ICU
c) Admit general medical ward

  B
Patient was presented with malignant HT and therefore must be admitted to ICU/CCU for close monitor with intra-arterial line.
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2.

What is shown in the ECG?
a) Normal ECG
b) ST elevation myocardial infarction
c) Left ventricular hypertrophy

  C
CORNELL Voltage Criteria for LVH
(Sensitivity = 22%, specificity = 95%)
• S in V3 + R in aVL > 24 mm (men)
• S in V3 + R in aVL > 20 mm (women)
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3.

What is shown in the CXR?
a) Cardiomegaly
b) Pulmonary congestion
c) Widened mediastinum

  A
Cardiothoracic ratio is more than 50%.
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4.

What are the abnormalities in the CT Abdomen?
a) Renal artery stenosis
b) Renal cysts
c) Normal

  A, B
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5.

What will you do next based on the CT diagnosis?
a) Refer for renal artery stenting
b) Family screening
c) Refer for renal dialysis

  A, B
Renal artery stenosis is the cause of renal
impairment and poor controlled HT and the
definitive treatment is renal artery stenting.
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Dermatology Series 皮膚科病例研究

Dermatology Series for December 2017 is provided by:
Dr. CHAN Hau Ngai, Kingsley, Dr. TANG Yuk Ming, William, Dr. KWAN Chi Keung, Dr. LEUNG Wai Yiu and Dr. CHANG Mee, Mimi
Specialists in Dermatology & Venereology
十二月皮膚科個案研究之內容承蒙陳厚毅醫生、鄧旭明醫生、關志強醫生、梁偉耀醫生張苗醫生提供。

A 52year-old lady complained of painful rash over body for few months

A 52-year-old lady with good past health complained of two painful rashes over trunk for two days. Physical examination showed well defined erythematous patches over trunk associated with erosion. She was not on any medication and there was no other body part involved.

Answers

1. What is the clinical diagnosis?
a. Eczema
b. Burn
c. Psoriasis
d. Skin cancer
e. Drug eruption
  B
The clinical diagnosis is thermal burn. This lady used an electric blanket while she was sleeping. She subsequently developed the painful patches afterwards.
 

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2. This skin disease can be diagnosed clinically. (T/F)
T
Thermal burn can be diagnosed clinically by medical history and physical examination. Only for complicated case or suspicious case, skin biopsy may be needed to exclude other medical diseases - drug eruption, psoriasis.
 

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3. This skin condition status can be classified according to the following:
a. Size
b. Depth
c. All of the above
d. None of the above
C
Burns can be classified according to the depth of the skin lesions into first, second, third and fourth degree burns. Also 'the Rules of nines' can be used to estimate the extent of total body surface area. This approach divides the different the body into percentages of total body surface area.
 

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4. What is the best medication of this skin disease?
a. Topical steroid
b. Topical antibiotic
c. Moisturizer
d. All of the above
B
The electric blanket causes a secondary thermal burn for this patient complicated by secondary infection. Topical and oral antibiotics are the best treatments to manage the wound.
 

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