24.A 31-year-old kindergarten teacher presents to the ED complaining of
acute onset substernal chest pain that is sharp in nature and radiates to her
back. The pain is worse when she is lying down on the stretcher and
improves when she sits up. She smokes cigarettes occasionally and was told
she has borderline diabetes. She denies any recent surgeries or long travel.
Her BP is 145/85 mm Hg, HR is 99 beats per minute, RR is 18 breaths per
minute, and temperature is 100.6°F. Examination of her chest reveals clear
lungs and a friction rub. Her abdomen is soft and nontender to palpation.
Her legs are not swollen. Chest radiography and echocardiography are
unremarkable. Her ECG is shown below. Which of the following is the most
appropriate next step in management?
14 Emergency Medicine
a. Anticoagulate and CT scan to evaluate for a PE
b. Prescribe a NSAID and discharge the patient
c. Aspirin, heparin, clopidogrel, and admit for ACS
d. Administer thrombolytics if the pain persists
e. Prescribe antibiotics and discharge the patient
25.A 71-year-old man is playing cards with some friends when he starts
to feel a pain in the left side of his chest. His fingers in the left hand become
numb and he feels short of breath. His wife calls the ambulance and he is
brought to the hospital. In the ED, an ECG is performed. Which of the fol-
lowing best describes the order of ECG changes seen in an MI?
a. Hyperacute T wave, ST-segment elevation, Q wave
b. Q wave, ST-segment elevation, hyperacute T wave
c. Hyperacute T wave, Q wave, ST-segment elevation
d. ST-segment elevation, Q wave, hyperacute T wave
e. ST-segment elevation, hyperacute T wave, Q wave
(Reproduced, with permission, from Fuster V et al.Hurst’s The Heart. New York, NY: McGraw-Hill,
2004: 304)