11.A 31-year-old man who works for a moving company presents to the
ED because he thought he was having a heart attack. He does not smoke, and
jogs 3 days a week. His father died of a heart attack in his sixties. He
describes a gradual onset of chest pain that is worse with activity and resolves
when he is at rest. His HR is 68 beats per minute, BP is 120/70 mm Hg, and
RR is 14 breaths per minute. On examination, his lungs are clear and there is
no cardiac murmur. You palpate tenderness over the left sternal border at the
third and fourth rib. An ECG reveals sinus rhythm at a rate of 65. A chest
radiograph shows no infiltrates or pneumothorax. Which of the following is
the most appropriate next step in management?
a. Administer aspirin and send for a troponin.
b. Administer aspirin, clopidogrel, and heparin and admit for acute coronary
syndrome (ACS).
c. Administer ibuprofen and reassure the patient that he is not having a heart
attack.
d. Inject corticosteroid into the costochondral joint to reduce inflammation.
e. Observe the patient for 6 hours.
12.A 21-year-old woman presents to the ED complaining of lightheaded-
ness. Her symptoms appeared 45 minutes ago. She has no other symptoms
and is not on any medications. She has a medical history of mitral valve
prolapse. Her HR is 170 beats per minute and BP is 105/55 mm Hg. Physi-
cal examination is unremarkable. After administering the appropriate med-
ication, her HR slows down and her symptoms resolve. You repeat a 12-lead
ECG that shows a rate of 89 beats per minute with a regular rhythm. The PR
interval measures 100 msec and there is a slurred upstroke of the QRS com-
plex. Based on this information, which of the following is the most likely
diagnosis?
a. Ventricular tachycardia
b. Atrial flutter with 3:1 block
c. Atrial fibrillation
d. Lown-Ganong-Levine (LGL) syndrome
e. Wolff-Parkinson-White (WPW) syndrome
8 Emergency Medicine