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Chest pain

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Chest pain. Discuss about 3 diagnostic consideration (MI, Musculoskeletal, Pneumonia) and make differential diagnosis.Conclusion is MI. I have done mostly on my own. It would be appreciated if the writer can check my case study and change or add as required to make the better case study.

Chest Pain
Introduction & Overview
Chest pain is the second most common reason for ED visits in U.S. Every year 6.2 million people with complaints of chest pain are seen in U.S emergency departments, which accounting for approximately 6% of ED visit. Cause of chest pain ranges from benign to life-threatening and there are many differential diagnoses we need to consider such as cardiac, pulmonary, gastrointestinal, vascular, musculoskeletal and psychiatric. (Tabas, 2013) (Mike D Cadogan MA (Oxon), 2011)
Myocardial infarction (MI) is the most common cause of death in adult over the age 40 in U.S. (D, 2016) Therefore It is vital to exclude ACS. The history is one of the most significant aspects in diagnostic consideration of chest pain. (Mike D Cadogan MA (Oxon), 2011) 107 /100 words

General appearance / PC /General History
I can make a patient so I made Mr K, who is likely to have a heart attack. I would like to keep the time of onset and radiation as they are the key points and his current medical and family history. Needs to refer to Bate?s guide to physical examination and history taking 11th edition Lynn S. Bickley
Mr. K is a 64 year old single NZ European male, lawyer is pleasant to speak with and cooperative. He is alert and cognitively intact.
Chief Complaints
Mr K was admitted to the emergency department with the chief complain of L) sided chest pain radiating to L) upper arm at 9:00 am on 5 June 2016. Initially the pain started around 08:20 am after waking up from his L) side. He verbalised ?At first, I thought the pain was just because of stiffness in my L) side. So I took a couple of paracetamol but it wasn?t working rather got worse.? ?I was also a bit nauseated and sweaty and I felt something is not right? Soon after he called ambulance by himself.
Present illness
Chest pain- He characterised the pain dull and heaviness in his chest radiating to the L) upper arm and scored it to 7-8/10 which is severe. It was a sudden onset and had lasted for almost 40min. It was also associated with sweating, nausea and SOB. No change in movement and no effect with general analgesia.
MHx: Hypertension, Hyperlipidaemia (Dyslipidaemia), Type 2 Diabetes, TIA
Mr K had developed Lower Respiratory Tract Infection (LRTI) and completed Amoxil 500mg TDS for 5 days a couple days ago.
Medications: Diltainzem 120mg OD ,Sinvastin 40mg OD, Metformin 1g BD /Allergies: Nil known allergies /174cm, 90kg BMI= Smoking: ? packet a day /Alcohol: /Diet: His diet is poor since he divorced. Usually eats take away food and hardly eats vegs.
/Exercise /stressful situation (of being busy with work, divorce and the loss of his sister)
Past History
Nil any major illnesses except an episode of TIA in 2014. He is prone to have DOE (Dyspnea on exertion), cough, cold and LRTI. He had a flu vaccine in April 2016 and completed his immunisations and vaccines as a child.
Family History
Please refer to the diagram.

Personal and Social History: Mr K?s lifestyle is sedentary (office work as a lawyer and hobby is reading and movies) It had been stressful due to the difficult law case. He lives independently in two bed room apartment and no assistance required for his ADLs. He has two sons but both live in overseas and no family support.
Review of Systems (Lynn S. Bickley, 2013)
General: Overweight, weakness, sweating, pale.
Skin: no rashes, lumps, sores, itching. Over all dry skin.
Head, Eyes, Ears, Nose, Throat (HEENT):
Head: No head injury, headache, dizziness. Eyes: No redness, eye discharge, pain, double or blurred vision. No MHx of glaucoma or cataract. Wears reading eye glasses. Last eye exmamination Ears: Both symmetrical. No infection, earaches, discharge, vertigo, tinnitus. No hearing aids. Nose: Has colds, stuffiness, sneeze, discharge (clear to yellowish in colour) especially in winter. No itching, hay fever. Throat: No sore throat, hoarseness but a bit of discomfort and irritation at times.
Neck: No swollen glands, pain or stiffness.
Breasts: No traumatic injury such as bruises, swelling or redness. No lumps or nipple discharge.
Respiratory: occasional cough (productive), sputum (clear-yellowish in colour), SOB noted but no wheeziness or cyanosis. Completed Amoxil 500mg for 5 days for LRTI recently. No MHx of COPD.
Cardiovascular: c/o chest pain. Pale and all extremities are a bit cold with poor capillary refill on fingers. No oedema, palpitations or apparent Ss and Sx of CHF.
Gastrointestinal: nausea (+) No abdominal pain, heartburn, dysphargia, diarrhoea or constipation.
Peripheral vascular: No varicose veins, leg cramps or oedema.
Urinary: Frequency of urination, nocturia and stress incontinence at times. No pain, discomfort or burning sensation in urination. No haematuria or concentrated urine. No kidney or flank pain.
Genital: No penile discharge or lesions. No scrotal pain or welling. No hernia. No STDs and currently not sexually active.
Musculoskeletal: joint pain (moderate 5/10) in both shoulders (+) sometimes. Stiffness and minor pain from neck, shoulder to back (+) when remaining in the same position. Takes paracetamol 1g as required with good effect. No other muscle or joint pain. No inflammation noted.
Psychiatric: Low mood sometimes but no depression, anxiety, memory changes. Current MMSE =29/30 and cognitively intact.
Neurologic: LOC is alert and oriented to person, time and place. No changes in mood attention or speech. No headache, dizziness, numbness, paralysis, tremors or seizures.
Hematologic: No easy bruising or bleeding. Not on anticoagulant medications but on aspirin 100mg. No anemia or past blood transfusion.
Endocrine: No thyroid problems. No heart or cold intolerance or excessive sweats. 695/500 words
Three Early Diagnostic Considerations
In developing countries, the leading cause of death is Coronary Artery Disease (CAD). When a patient complaint of ?chest pain?, CAD must be considered first due to life-threating condition then reflects other common probabilities linking to history, risk factors and general appearance (Mike D Cadogan MA (Oxon), 2011). Mr K has several risk factors of CAD such as smoking, dyslipdemia, HTN, DM and obesity. Moreover he has family history of MI. Considering epidemiology of MI, 70% of patients with MI are men. [5] Therefore 1) Myocardial Infarction (MI) must be considered and excluded first.
Chest pain related to 2) Musculoskeletal is the most common aetiologies (36%) in the primary care setting. (James E. Brown, Assessment of chest pain, 2016) Mr K has musculoskeletal problems at times and on PRN Paracetamol 1g QID. He was remaining in the same position on his L) side prior to having the chest. In addition, he had a recent episode of prolonged cough, which is risk factor of microtrauma. Musculoskeletal is also one of diagnostic considerations as verbalised by Mr K as his initial thoughts.
Typical symptoms of pneumonia might include fever, cough, SOB and chest pain. (Group, 2016) Those symptoms were observed upon Mr K?s initial assessment except fever. Furthermore, he had been suffering from LRTI and Mr K is diabetic and very vulnerable to develop infection and aggravate his condition. 3) Pneumonia might have attributed to his chest pain.227/200words

Physical Examination/Vital sign
Physical examination takes a very important role to lead to the most probable differential diagnoses.
Vs: BP=98/60, P=52 regular, R=28, SP02=92-93%, T=36.9
Needs to refer to Bate?s guide to physical examination and history taking 11th edition Lynn S. Bickley
I focused on cardiopulmonary examination as well as musculoskeletal. Would you add that other body parts examination was performed and nil remarkable noted?
Cardiovascular
Would you add a simple explanation about JVT, PMI, heart murmurs and why we need to examine?
Inspection: Peripheral signs- Clubbing (-) Splinter haemorrhage (-) Janeway lesions (-).The limbs – Varicose Veins (-) peripheral oedema (-) Skin colour is pale. The Anterior Chest- Scars (-) Pint of Maximum Impulse (PMI) is not visible. The Neck Vessels-Standing on the R) side of Mr K and the head of his bed is elevated at 30 degree to examine the Jugular Venous Pulse (JVP). [4] The JVP is 5.5cm above the sternal angle. Carotid upstrokes are brisk without major bruits.
Palpation: The Limbs- slightly cold and cold sweating. Capillary refill time 2 sec. Tenderness (-) Pulses-radial, brachial, popliteal, posterior tibialis, dorsalis pedis are a bit weak and bradycardia but equal bilaterally. The Carotid Artery- amplitude of the pulse (+1) weak and equal bilaterally. The Precordium- A thrill (-) at the apex, the L) sternal border and the base. The Apical Impulse- the point of maximal impulse (PMI) is slightly diffuse and 3cm in diameter, palpated at the midclavicular line in the 5th intercostal space.
Auscultation: The Carotid Artery- a bruit (-) at the angle of the jaw, the midcervical area and the base of the neck. The Heart Sounds- the diaphragm and bell of the stethoscope are used to listen to the four traditional valve areas-1) Aortic, 2) Pulmonary, 3) Tricuspid, 4) Mitral area. Timing, duration, pitch and intensity are also examined. S1 normal. S2 split. High-pitched sounds. The tricuspid murmur (+) and a holosystolic murmur is heard at the L) lower sternal border. [9,10] Heart sounds include a holosystolic murmur heard best at the left middle or lower sternal bord
Percussion: Please refer to respiratory examination.
Respiratory exam / Thorax and Lungs
Inspection: Deformities(-) Scars(-) Asymmetry (-) No cyanosis but skin colour is pallor. Impaired respiratory movement (-) Ragging (-) and breathing pattern is regular but slightly rapid. Palpation: Tenderness (-) carefully examined around the 2nd to 5th costochondral joints.costrochonditis Trauma(-) Masses(-) Crepitus(-)thoracic injury. Posterior chest expansion- Symmetric. Unequal chest expansion (-). Tactile Fremitus-Increased or decreased asymmetric fremitus (-) happens with pneumonia
Percussion: Lungs resonant. Dullness(-), Hyperresonant(-)
Auscultation: Breath sounds vesicular, Crackles (-), wheeziness(-), Rhonchi(-)

Musculoskeletal: Palpation: No tenderness or inflammation on the sternal and xiphoid area, constosternal junctions especially the 2nd to the 5th and anterior chest wall where tenderness is most common. [ www.ncbi.nlm.nih.gov/pubmed/1543409 ]
www.ncbi.nlm.nih.gov/pubmed/1543409 Arch Phys Med Rehabil. 1992 Feb;73(2):147-9.
Musculoskeletal chest wall syndromes in patients with noncardiac chest pain: a study of 100 patients.
Wise CM1, Semble EL, Dalton CB.

420 /500 wards

Differential Diagnosis
First of all, it is important to differentiate the causes of chest pain 1) Cardiac pain or 2) Non-cardiac pain. If it is cardiac pain, other signs and symptoms associated with cardiac problems are often manifested. Considering 1) Traumatic or 2) Non traumatic pain is also vital. (Mike D Cadogan MA (Oxon), 2011)
Considering Mr K?s history and risk factors, MI is the most prioritized concern and it is necessary to rule out the most unlikely diagnosis. A musculoskeletal diagnosis can be identified by clinical examination and pain assessment alone. Chest pain on specific posture or physical activities suggest a musculoskeletal cause. It is also the key to assess if the pain is reproduced by either a movement or palpation over the chest. (S, 2001) (Fadi Badlissi, 2016) According to Mr K?s clinical examination, there was no tenderness on the common locations of the thorax or reproducing his pain on palpation. Most importantly, Mr K?s onset of chest pain was sudden and not exacerbated on movements of the chest, which contradicts the likelihood of musculoskeletal. (Group, 2016) Thus, musculoskeletal aetiology is very low for Mr K?s case. Moreover, Mr K manifested some associated symptoms of chest pain such as ??P or BP, SOB or nausea which unlikely to occur to musculoskeletal and it strongly supports for cardiopulmonary diagnostic considerations such as MI and Pneumonia. 220 /200 words.

Diagnostic Test
The best possible diagnostic test is lead through comprehensive history, risk factors, pain assessment and clinical findings.
The electrocardiograph (ECG) remains the most widely performed diagnostic tool in CCU and is the highly practical measure of evaluation of the electrical movement of the heart. A considerable amount of information in regarding MI and infarction is obtained by the standard 12 lead ECG. Thus, ECG should be performed as the first diagnostic test for all patients with chest pain within 10 min of emergency depart arrival to differentiate diagnosis of chest pain. The ST segments, development of Q waves and T waves are most considerable changes in ECG which are manifested by infarction related arteries. Especially ST abnormalities are the earliest findings of MI. (Thompson, 2011) According to ESC, ACCF, and AHA committee, the definition for the diagnosis of ST elevation MI is ST elevation in two contiguous leads 2mm in men and 1.5mm in women in precordial leads and 1mm in limb leads.[3] A patient is suspected inferior MI, it is vital to obtain right-sided ECG leads to identify ST elevation suggestive of right ventricular.
On the other hand, ST-segment elevation MI is found in approximately 30% of patients with ACS and ST-segment change is not obvious for unstable angina and non ST-segment MI. [3] Therefore continuously monitoring cardiac enzymes is very important to specifically confirm MI.
In myocardial necrosis, structural proteins and intracellular macromolecules are released into the cardiac interstitium, such as Cardiac troponin (cTn), creatine kinase (CK) and myoglobin. cTnT or cTnI is preferred biomarker for myocardial necrosis as it has almost absolute myocardial tissue specificity and high clinical sensitivity. (Ross, Bever, Uddin, & Hockman, 2000)
The diagnosis of MI depends on an evidence of myocardial ischemia with an increased cTn level exceeding the 99th percentile and indicating an increase or decrease over time. (Ru-Yi Xu, 2013) According to American Heart Association (AHA)?s guideline in 2014, diagnosis of MI is defined as quote: ?when the troponin rises or falls. If the initial troponin is elevated the diagnosis is made if a = 20% rise or fall in subsequent troponins occurs.? CK-MB is no longer recommended for diagnosis of MI and should be remained for estimating size of infarct. (Ru-Yi Xu, 2013)
The research for troponin I sensitivity and specificity for diagnosis of MI shows that when a troponin I level >2.0ng/mL was regarded as a positive value when compared to ECG and CK-MB, sensitivity was 85% and specificity was 91%. (Ross, Bever, Uddin, & Hockman, 2000)
Therefore cTn test is golden standard as specificity diagnostic test for MI. [13]
Nevertheless, falsely positive results of cTn test should be considered in patients with renal failure, CHF, PE and AD.[3] Considering those patients or no obvious ECG or cardiac enzymes changes, precisely ruling out MI is very important.
It is vital to re-test cTn at 6-9 h after presentation to indicate sufficient clinical sensitivity. Moreover, high-sensitivity troponin (Hs-cTnT) has demonstrated an excellent diagnostic performance for the early diagnosis and prognosis value. (Ru-Yi Xu, 2013)
Chest X-ray is often taken to estimate CHF in patients with MI and it is also very useful to evaluate for early and late prognosis. Early detection of pulmonary venous congestion or cardiac enlargement is vital. Furthermore, A chest X-ray is the best diagnostic test for pneumonia [16] which means if no indication of pneumonia on the chest x-ray, the cause of chest pain related pneumonia is excluded at the early stage. 560/ 500 words

Males between the ages of 45 and 65 years are more prevalent to have MI. [3] Furthermore, according to his pain assessment, typical likelihood of MI is indicated as follows: a sudden onset, unspecific pain- dull and heaviness in his chest + radiating to L) upper arm and the time lasting more than 20min. The time of the incident is also considered as it is more common to have a heart attack between 4:00 and 10:00 am due to the higher adrenaline level which attribute to disruption of cholesterol plaques. [ Kulick & Lee, 2011] Most significantly, some signs and symptoms of cardiopulmonary abnormalities are observed during physical examination.
Diagnostic Reasoning
Clinical reasoning is pivotal process to interpret patient?s history, physical examination and clinical findings. It is assessed with rational through subjective date (history and risk factors) and objective date (examination and test).To evaluate and make clinical decisions based on clinical evidence, it is necessary to improve our knowledge of sensitivity, specificity, reliability, validity, predictive value, likelihood ratio and measurement of agreement and apply those to the clinical findings to enhance the clinical reasoning. (Lynn S. Bickley, 2013)
First of all, from his subjective date, considering Mr K?s medical, family history and risk factors Mr K and his family have strong risk factors which are accountable for MI such as hypertension, hypercholesterolemia, smoking, diabetes. In addition, his father had a MHx of MI. According to statistics / research, there is a strong relation between MI and risk factors?. Example research Mr K?s sedentary lifestyle, luck of exercise and poor diet are also significantly concerned. Gender is an another considerable point as 70% of patients with MI are man[Dynamed] . A Males between the ages of 45 and 65 years are more prevalent to have MI. (D, 2016) Mr K?s current stressful situation should not be underestimated. Therefore Mr K has a strong likelihood to develop MI through the above subjective date and risk factors, which are most the remarkable points for assessing probable MI.
In contrast, considering Mr K?s current lower respiratory tract infection, the possibility of pneumonia causing his chest pain cannot be denied. Especially Mr K is diabetic and more likely to develop infection and worsen the condition. Chest pain related to pneumonia is also referred to pleuritic pain due to inflammation of the parietal pleura as in pneumonia. (Lynn S. Bickley, 2013)
Pain is also very important subjective date. It is no exaggeration that through pain assessment could effectively facilitate to make differential diagnosis. Please refer to the tables for chest pain in comparison MI with pneumonia as per PQRST pain assessment as follows: (Lynn S. Bickley, 2013) I will make the following graph. I think graph is not counted as words!?
MI vs Pneumonia
P: Location? Across the anterior chest Chest wall
Cause? Necrosis of myocardia Inflammation of parictal pleura
What make it worse? No specific Deep inspiration/coughing

Q: Character? Vague sensation Sharp or Stabbing
Dull or Heaviness in chest

R: Radiate? Yes No
Diffuse. Difficult to localise Easy to describe and localise

S: Severity ? Often severe Severe

T: When and How? AM, Sudden onset Gradual onset
Time lasted More than 20 min persistent
According to Mr K?s pain assessment (PQRST), he has characteristic chest pain of MI as pain migration is present which is unlikely to pulmonary cause. Sudden onset, unspecific pain- dull and the time lasted more than 20min are also features of chest pain in MI. Typical pleuritic pain is unremarkable especially there is no aggravation on deep inspiration or coughing. Another considerable point is the time of onset as it is more common to have a heart attack around the sleep-to-awake with peak onset at 9:00 am due to thrombus formation and plaque rupture. (Maximilian J Schloss, 2016) This could further support the possibility of MI as Mr K?s chest pain occurred at 8:20am. Moremore, Mr K had no fever which is common symptoms of pneumonia. (Group, 2016) The possibility of chest pain related to pneumonia may be unlikely.
In regard to Mr K?s noticeable clinical findings such as bradycardia, hypotension, nausea and vomit, those are linked to typical presentations of inferior MI because of parasympathetic stimulation results in increased vagal tone. (KIMBERLEY A. LITTON, 2002) Cold sweat is more likely caused by sympathetic nerve reaction. Especially nausea / vomit are 58% more commonly observed in inferior MI. (Mahi L. Ashwath, 2016)
In addition, most remarkable Mr K?s clinical findings are elevated JVP because the triad of
increased JVP, hypotension and clear lung fields is well recognised indicator of RVI related to
inferior MI. According to research, this clinical triad was tested and confirmed
hemodynamicaly that it was 96% specific for infarction but only 25% sensitive. An
elevated JVP alone was 69% less specific but more 88% sensitive for right
ventricular infarction. (Thompson, 2011)
Considering Mr K?s cardiac auscultation, the presence of Tricuspid regurgitation could also support the likelihood of RVI results in enlarged right ventricular chamber.[ http://www.uthsc.edu/cardiology/articles/RVinfarctReview.pdf ] Right Ventricular Infarction?Diagnosis and Treatment SHOWKAT A. HAJI, M.D., AND ASSADMOVAHED, M.D., FACP, FACC Section of Cardiology, Department of Medicine, East Carolina University School of Medicine, Greenville, North Carolina, USA

Trisupid regurgition(TR) is mostly secondary caused by dilation of the right ventricle. A holosytotic murmur and neck pulsations are common
signs in severe TR and could cause right ventricular-induced heart failure. [17] Considering Mr K?s clinical assessment,
On the other hands, according to Mr K?s clinical examination, there were no remarkable findings related to pneumonia such as fever, rale, wheeziness, cough, phlegm noted in pulmonary examination.
Inferior MI is caused for 40-50% of all MI [19]. Familiarising the typical clinical findings of inferior MI could facilitate to the likelihood of MI definite as they are often noticeable and legible on both clinical examination and ECG. To establish the diagnosis and location of MI, ECG and troponin test are most essential.
Mr K?s ECG shows ST elevation 2mm in II, III, aVF, V1, V3R, V4R and development of Q waves in II, III, aVF which indicates typical ECG findings of inferior MI and right ventricular infarction as indicated as follows. (Thompson, 2011)
Position ECG leads Infarct-related artery
Inferior II, III, aVF Right or posterolateral of circumflex
Right ventricular V 3 R, V 4 R Right coronary

More than 80% of inferior MI is caused by occlusion of the dominant RCA. [19] More specifically, Inferior MI with no lateral or posterior changes represents right coronary artery inclusion with 97% of specificity and 56% of sensitivity. (Thompson, 2011) Mr K?s abnormal findings of ECG strongly support MI especially inferior MI and right ventricular infarction and this probability is also dominant from the above study.
Up to 40% patients with an inferior MI will have a related to right ventricular infarction.[19]
This probable diagnosis of MI is more significantly determined by cTn which is golden standard diagnostic test of MI. Mr K?s cTn result shows ******** which indicate positive for MI.
According to Mr K?s Chest X-ray, chest is clear and there is no apparent abnormalities
found. The presence of clear lung fields of Mr K?s chest X-ray strongly indicates not only
excluding pneumonia but also strongly support MI (right ventricular infarction) because of
one of the clinical triad. Diagnosing pneumonia by chest X-ray may not be sufficient as pneumonia could develop after 48 hours of admission and may not noticeable on admission.
However considering Mr K?s comprehensive assessment and diagnostic test, MI is the most likelihood of prognosis.

Overview of Pneumonia Download PDF
? Daniel M. Musher
Goldman-Cecil Medicine, 97, 610-620.e2

Radiographic Findings
Pneumonia is usually diagnosed by the presence of an infiltrate on a chest radiograph or excluded by the absence of an infiltrate. A dense consolidation that involves a segment or a lobe of the lung is very likely to reflect an acute bacterial infection. Many patients with bacterial pneumonia, however, have radiographic infiltrates that are not clearly segmental. Small areas of alveolar consolidation may be missed by a chest radiograph, especially an anterior-posterior portable radiograph, but be detected by the far more sensitive computed tomography (CT) scan. 2 However, small areas of consolidation (ground-glass appearance) are often described on the CT scan of patients who do not have pneumonia.
Although the presence of an infiltrate is the key to making a diagnosis of pneumonia, its radiographic appearance provides very little insight into the etiology. Dense consolidation of a segment or lobe is usually bacterial ( Fig. 97-1 ), especially pneumococcal, but other bacteria, including Legionella ( Fig. 97-2 ), may cause a similar picture, but many bacterial pneumonias do not cause segmental or lobar infiltrates.
clear lung fields is also one of clinical triad of RVI.

Conclusion
Making the differential diagnosis of patients with chest pain can be complicated due to the five anatomic groups of structures in the thorax and many its causes are involved and related. Cardiac problems especially MI often involves pulmonary and gastrointestinal symptoms which make diagnostic process even more complex. It is vital to exclude the life-threating cause which is related to cardiac or not. Proper history taking and considering risk factors are most essential for identifying cardiac pain as there is strong evidence between MI and risk factors such as smoking, dyslipidemias, HTN, DM and obesity. It is also necessary to rule out musculoskeletal cause which is the common cause of chest pain. Based on detailed pain assessment and vital signs, it may be possible to distinguish the cause of chest pain related to cardiac or non-cardiac. Physical examination and diagnostic test are fundamentally vital to make evidence-based diagnostic reasoning, which lead to the best possible diagnosis and facilitate to commence on appropriate treatment as soon as possible. In Mr K?s case, MI is highly supported and established with high-sensitivity troponin (hs-cTnT), which shows strong sensitivity and is an excellent indicator for making an early diagnosis of MI and even its mortality. 202 words

References
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ARTICLEEpisodes of care for chest pain: a preliminary report from MIRNET.
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[10] http://www.easyauscultation.com/
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? Peter L. Thompson Coronary Care Manual, Second Edition This edition ? 2011 Elsevier Australia 69, 522-525
? http://www.ncbi.nlm.nih.gov/pubmed/1543409 Arch Phys Med Rehabil. 1992 Feb;73(2):147-9.
? Musculoskeletal chest wall syndromes in patients with noncardiac chest pain: a study of 100 patients.
? Wise CM1, Semble EL, Dalton CB.

http://www.ncbi.nlm.nih.gov/pubmed/11676310 Aust Fam Physician. 2001 Sep;30(9):834-9.Musculoskeletal causes of chest pain.Jensen S1.

[12] http://emedicine.medscape.com/article/811905-overview#a2 Cardiac Markers
? Author: Donald Schreiber, MD, CM; Chief Editor: Barry E Brenner, MD, PhD, FACEP more…

[13] http://professional.heart.org/professional/ScienceNews/UCM_466977_2014-NSTE-ACS-Clinical-Practice-Guidelines—-Whats-New.jsp
[14] http://www.ncbi.nlm.nih.gov/pubmed/10693314J Am Osteopath Assoc. 2000 Jan;100(1):2932. www.ncbi.nlm.nih.gov/pubmed/10693314
21/08/2016 ? 1. J Am Osteopath Assoc. 2000 Jan;100(1):29-32. Troponin I sensitivity and specificity for the diagnosis of acute myocardial infarction
Troponin I sensitivity and specificity for the diagnosis of acutemyocardial infarction
[15] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3627711/#b18 High-sensitive cardiac troponin TRu-Yi Xu,1 Xiao-Fa Zhu,1 Ye Yang,1 and Ping Ye2
[16] http://circ.ahajournals.org/content/circulationaha/61/5/1004.full.pdf The Initial Chest X-ray in Acute Myocardial Infarction
circ.ahajournals.org/content/circulationaha/61/5/1004…
The Initial Chest X-ray in Acute Myocardial Infarction Prediction of Early and Late Mortality and Survival ALEXANDER BATTLER, M.D., JOEL S. KARLINER, M.D., CHARLES B. HIGGINS, M.D., ROBERT SLUTSKY, M.D., ELIZABETH A. …

[17] http://www.nhlbi.nih.gov/health/health-topics/topics/pnu/diagnosis pneumonia diagnostic test
[18] http://www.merckmanuals.com/professional/cardiovascular-disorders/valvular-disorders/tricuspid-regurgitation
[19] inferior STEMI http://lifeinthefastlane.com/ecg-library/basics/inferior-stemi/

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Caspian J Intern Med. 2014 Winter;5(1):13-6.
Clinical manifestations of right ventricle involvement in inferior myocardial infarction.
Khosoosi Niaki M1, Abbaszade Marzbali N2, Salehiomran M1.
Author information
Abstract
BACKGROUND:
Early diagnosis of right ventricle (RV) involvement in inferior myocardial infarction (Inf MI) is very critical. This study was performed to evaluate the clinical findings of Inf MI with or without RV infarction.
METHODS:
From September 2010 to September 2012, 195 patients with definite diagnosis of Inf MI were evaluated in the Department of Cardiology, in Babol, north of Iran. The presence or absence of right ventricular infarction was evaluated by ST elevation in preicordial V3R-V4R leads. Chest pain (CP), changes in electrocardiography (ECG), serum level of Troponin T (TnT), decreased level of consciousness, hypotension, and jugular vein prominence (JVP) in patients with and without RV involvement were noted.
RESULTS:
One hundred forty eight (95 males and 53 females) and 47 (31 males and 16 females) cases developed Inf MI without and with RV infarction, respectively. The mean age of the patients with and without RV infarction were 60.59?12.9 and 60.9?12.2 years, respectively (P=0.883). CP, decreased consciousness, hypotension, and JVP were seen in 147 (99.3%), 1 (0.7%), 1 (0.7%) and 1 (0.7%) patients without RV involvement and in 44 (93.6%), 9 (19.1%), 27 (54.4%) and 9 (19.1) in RV involvement, respectively (p<0.05). No significant differences were seen in ThT enzymes and ECG changes.
CONCLUSION:
The results show that chest pain, decrease of consciousness, hypotension, JVP prominence are more frequent in inferior MI with RV involvement patie

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