A 70 year old male patient presented to the emergency depament with pain in epigastrium and difficulty in breathing for 6 hours. On examination, his hea rate was chest examination was normal. The patient has been taking omeprazole for gastresophageal reflux disease for last 6 months. What should be the intial investigation :

Answer is A (An ECG) The patient in question may well be suffering from an acute myocardial infarction. An ECG to exculde an acute MI should be the initial Investigation. `Presence of Epigastric pain in association with breathlessness and evidence of parasympathetic overactivity (bradycardia and hypotension) suggests the diagnosis of an acute (inferior) MI.' ECG therefore should be done as an initial investigation to exclude / confirm a diagnosis of acute MI.' The following lines from Harrison give away the answer to the question : 'Typically the pain involves the central poion of chest and / or epigastrum'. 'The frequent location of the pain beneath the xiphoid and patients denial that they may be suffering a hea attack are chiefly responsible for the common mistaken impression of indigestion. In the elderly, MI may present with sudden onset breathlessness. Although many patients have a normal pulse and blood pressure about one fouh of patients with anterior infarction have manifestations of sympathetic nervous system hyperactivity (tachycardia and / or hypeension) and upto one half with inferior infarction show evidence of parasympathetic hyperactivity (bradycardia and /or hypotension).