Case of the month: Heaviness of arm in an elderly female with long standing diabetes mellitus !
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Case of the month: Heaviness of arm in an elderly female with long standing diabetes mellitus !

 Clinical scenario : 

                A 76 yr old female  complained of heaviness of her left arm  and some discomfort on right side of chest. The pain was mild and severity was just  1/10 and it was not  associated with diaphoresis .
There was no history of shortness of breath , dizziness or  palpitations . She has been diabetic for last 20 years on oral hypoglycemic drugs .There was no history of Hypertension and her Lipid estimation few months back were normal . No family history of sudden death or coronary events .

She was conscious oriented .Pulse was 72/min regular , synchronous with other pulses and there was no radiofemoral delay. The volume was good and it had no special character .
Her JVP was not elevated .There was no pallor or lymphadenopathy
Chest : Trachea was central , movements of the chest were normal and on persuasion there was no dullness  . Bronchovesicular breathing was heard without any added sounds.
CVS: S1 and S2 were normally heard and there was no gallop or pericardial rub
Abdominal examination was normal .
CNS : Normal

Evaluation : 

Her Hemoglobin levels were 14gm/dl .She had normal WBC and platelet counts. Her routine ECG showed Fig 1  ST segment elevation in leads II, III, and AVF (Inferior leads )

Fig 1 ECG showing ST elevation in inferior leads and in chest leads as above



There is also elevation of ST segment in leads V5 and V6 fig 2 (Lateral leads) and ST depression in V1 and V2 (posterior leads )



Fig 2 Right ventricular leads showing ST elevation in V3R, V4R


Then  ECG of right ventricular Leads  was taken which showed ST elevation in V3R and V4R  (Fig 2).She had Positive Troponin I .The final diagnosis was  Acute inferoposterolateral myocardial infarction with right ventricular extension.

She was managed in coronary care unit as acute Myocardial infarction Killip class I (Click to read Killip classification)  .She  was given loading dose of Tab Aspirin and Clopedogril and Alteplase thrombolysis was started Click to read detailed information about thrombolysis   Within half an hour her pain settled and the repeat ECG after thrombolysis is shown in Fig 3



Fig 3 Repeat ECG after thrombolysis showing no ST elevation and appearance of Q waves


There is Qs with T wave inversion in inferior leads II,III,AVF  .There is no more  ST elevation in lateral leads and no ST depression in posterior leads

She was taken up for coronary angio few days after .

Teaching message :

is very important to have high suspicion of myocardial infarction in diabetics . It may be painless and may present with atypical symptoms like jaw pain , epigastric pain , nuchal pain or a simple black out . It may not always present in a classical fashion.

Further Reading:   Myocardial infarction   

This case was Contributed by :
Dr Elshazly Abdul Khaliq MD

Consultant Cardiologist 

King Abdul Aziz Specialist Hospital Taif Saudi Arabia 


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