Inferior MI with posterior extension - by. Dr. Md. Maksud Islam Shamim

Inferior wall myocardial ischemia with extension to posterior wall

1. Welcome to weekly
Clinical case presentation
Dr. Md Maksud Islam
Intern Doctor
Colonel Maleque Medical College Hospital, Manikganj

2. Scenario:
● A case of 35 years young man presented with chest pain and vomiting for 02
episodes

3. Particulars of the
patient:
❏ Name: Ashwini Rajbongshi
❏ Age: 35 years
❏ Sex : Male
❏ Occupation:
Pharmacy Assistant
❏ Religion: Hindu
❏ Marital status: Married

4. Cont.

❏ Address :
Alinagar, Gharpara, Manikganj
❏ Date of admission:
24/07/2024
❏ Date of examination :
29/07/2024
❏ Ward: CCU

5. Chief
complaints:
●Sudden onset of Chest pain for
2 hour
●Vomiting for 02 episodes

6. History of present illness
●According to the statement of the patient , he was reasonably well 02 hours back
then he developed sudden, severe chest pain which was squeezing in
nature,which radiate to neck, jaw and left arm and associated with sweating and
vomiting for 2 episodes.He expressed fear of Impending to death with severe
pain. The pain was not associated with food and changing posture.
●He has no suggestive history of asthma or cough or breathlessness with
seasonal variation.

7. Cont.
●There is no history of fever, cough, hemoptysis, recent surgey or
any recent chest trauma. His bowel and bladder habits are
normal.

8. History of past
illnesses
●He is non diabetic,
normotensive, no history of
PTB & Asthma.

9. Family history :
●He has two son and his
wife.
All the family members are
healthy

10. Personal history
●He is non smoker, and
occasionally alcoholic

11. Socioeconomic
history :
●He comes from middle
class family, and lives in a
tin shed house with good
sanitation and water
supply.

12. Drug history : ●Nothing
significant

13. Immunization
History
●He had completed all
doses of covid-19
vaccine.

14. Allergic history
●Patient is not allergic to
any food, dust, fume or
pollens.

15. General examination :
❏ Appearance : Anxious
❏ Body Built: Average
❏ Co-Operation : Co-operative
❏ Decubitus: Propped up position
❏ Intelligence : Intelligent
❏ Nutritional status : Average
❏ Anemia: Absent
❏ Jaundice : Absent

16. Cont:
❏ Cyanosis:absent
❏ Clubbing : absent
❏ Koilonychia:absent
❏ Leukonychia: absent
❏ Pulse: 85 b/min
❏ Blood pressure : 120/80 mmHg
❏ Respiratory Rate: 24 breath/min
❏ Temperature: Normal

17. Cont.
❏ Edema: absent
❏ Dehydration:absent
❏ SpO2: 99% with oxygen.
❏ Neck vein: not raised
❏ Thyroid gland: not palpable
❏ Lymph node: not palpable
❏ Hair distribution : normal
❏ Skin condition: normal
❏Cannula on situ in left hand

18. Cardiovascular system examination :
●Inspection: Shape of chest is normal. There is no visible cardiac impulse,no
visible pulsation or engorged vein.There is no scar mark, abnormal pigmentation,
or any visible swelling. Skin condition and hair distribution is normal.
●Palpation:Apex beat is situated in left 5
th
inercostal space along the left mid
clavicular line about 9 cm away from the mid sternal line .
There is no thrill, left parasternal heave or palpable P2

19. Cont.
●Auscultation:1
st
and 2
nd
heart sound are audible in all 4 cardiac
areas.

20. Respiratory system examination :
Inspection:
●Shape : normal
●Chest movement : symmetrical
●Prominence of accessory muscle of respiration :absent
●No excavation of Suprasternal& supraclavicular space
●Intercostal space : normal

21. Cont.
Palpation:

●Position of the trachea: centrally placed
●Chest Expansion : symmetrical
●Vocal fremitus: normal

22. Cont.
Percussion:

● Percussion note: Resonant
●Upper border of the liver dullness : Right 5
th
intercostal space in the midclavicular
line

23. Cont.
Auscultation:

●Breath sound : vesicular
●Added sound : Absent

24. Systemic examination
●Other systemic examination reveals normal

25. Salient Feature :
●Mr. Ashini Rajbongshi, 35 years old male, Hindu, Married,
Pharmacy assistant, Normotensive, Non diabetic, Non
smoker and occasionally alcoholic hailing from Alinagar,
Gharpara, Manikganj was admitted in CMMCH through
emergency department 23
th
July, 2024 with the chief
complaints of severe chest pain for the last 2 hours with
vomiting for 2 episodes.

26. Cont.
● He was reasonably well 2 hour back then he developed sudden, severe
chest pain. The pain was heavy and squeezing in nature, radiate to neck,
jaw and left arm. The pain was not associated with food or changing
posture .He has also history of vomiting for two episodes. There is no
seasonal variation of cough & he gave no suggestive history of bronchial
asthma. He also stated that he had never experienced this type of severe
chest pain before.

27. Cont.
●There is no history of fever, cough, hemoptysis, or any recent chest
trauma.
● His bowel and bladder habits are normal.
●There is no history of DM, IHD, PTB, Bronchial asthma.
●He is non smoker and occasionally alcoholic. He had taken all doses of
covid-19 vaccine and no significant allergic history.

28. Cont.
●On general examination , The patient is anxious, average body built,
cooperative and on propped up position. His pulse 80 b/min BP
130/80mmg ,RR 24 /min ,temperature normal and cannula in situ on left
hand. He was non anemic and absence of any cyanosis and clubbing. He
had no edema or ascites. His JVP was not raised, thyroid gland and
lymph node are not palpable.

29. Cont.
●On systemic examination, On cardiovascular system examination, Shape
of chest was normal. There was no visible cardiac impulse,no visible
pulsation or engorged vein.There was no scar mark, abnormal
pigmentation, or any visible swelling.
●Apex beat was normal and situated on the left 5
th
intercostal space along
the left mid clavicular line about 9 cm away from the mid sternal line.
There was no thrill, left parasternal heave or palpable P
2
.

30. Cont.
•On auscultation,1
st
and 2
nd
heart sound are audible in all 4 cardiac
areas.
•On respiratory system examination, On inspection Shape of the chest
was normal , Chest movement was symmetrical ,there was no
prominence of accessory muscle of respiration ,No excavation of
Suprasternal& supraclavicular space ,Intercostal space was normal.
•On palpation,Position of the trachea was centrally placed , Chest
Expansion was symmetrical ,Vocal fremitus was normal.

31. Cont.
On Percussion , Percussion note is resonant , Upper border of the liver
dullness is situated in the Right 5
th
intercostal space in the midclavicular
line. On Auscultation Breath sound is vesicular.

Examination of other system reveals no abnormality.

32. Provisional Diagnosis:
❏ Acute coronary syndrome

33. Differential
diagnosis :
❏Aortic dissection
❏Pericarditis
❏Pulmonary embolism

34. Investigations:
●ECG:
●HR : 88 /min
●Rhythm: regular (sinus
rhythm)
●Finding :
●ST elevation is found in II
,III and avF
●ST depression is present in
aVL and V2
●T inversion is present in
aVL ,V1 and V2

35. Right side ECG
Heart Rate - 75 /min
Rhythm - Regular (Sinus rhythm)

Findings -

ST depression in V1 and V2

36. After STK
ECG

37. Cont.
●Hb-13.4 g/dl
●Total WBC count- 20,180/cumm

38. Cont.
●Serum creatinine : 0.80 mg/dl
●RBS-7.9 mmol/L

39. Cont.
Sodium - 134.0 mmol/L, Potassium - 4.3 mmol/L, Chloride - 105.9 mmol/L

40. Further Investigation plan:
●Chest X ray P/A view
●Echocardiogram.

41. Confirmatory diagnosis :
Acute ST elevated Inferior Myocardial Infarction with posterior extension

42. Treatment :
❏On admission: Immediate treatment given
❏Diet : Liquid diet.
❏Bed rest with propped up position
❏O2 inhalation 2L/min stat and SOS
❏Tab. Aspirin + Clopidogrel 75 mg 4 tab stat
❏Tab. Atorvastatin 10 mg 4 tab stat
❏Inj.STK 1.5 million IU with 50 ml N/S over 1
hour.(Through syringe pump)
❏Inj Pethidine (100mg)-I/v Stat.
❏Inj. Ondansetron 8 mg/ml 1 amp I/V –stat.
❏Tab. Bisoprolol 2.5 mg
❏Tab. Ramoril 1.25 mg

43. Cont.
Treatment continued:

Tab. Aspirin + Clopidogrel 75 mg-
0+1+0 (After meal)
Tab. Atorvastatin 10 mg- 0+0+2
Tab. Nitroglycerin 2.6 mg 1+1+0
Tab.Bisoprolol 2.5mg 1+0+0
Tab Ramipril 1.25mg 0+0+1
Tab. Pantoprazole 20 mg 1+0+1
(B/M)
Tab. Trimetazidine 35 mg 1+0+1
Tab. Clonazepam 0.5 mg 0+0+1
Nitroglycerin spray 2 puffs s/L stat
& sos

44. Plan:
●Coronary angiogram

45. Advice to the
patient:
The patient was advised to follow
and maintain-
❏Adequate bed rest for 2 weeks.
❏Avoiding strenuous exercise and
practice light-weight physical
activity.
❏Avoiding intake of fatty foods.
❏Joining the workplace after 4-6
weeks.
❏Walking exercise everyday at least
30mins.
❏Encourage more vegetables & salt
restricted diet.
❏Visiting the OPD after 7 days.