Question of the Week

For March 26, 2024

A previously healthy 15-year-old girl presents to the emergency department with a 3-day history of sharp, left-sided, nonradiating chest pain that worsens with inspiration and lying down — and improves with sitting up and leaning forward. The patient also reports difficulty breathing and catching her breath. She recently traveled by air from San Francisco to New York and developed flulike symptoms (fever, rhinorrhea, and cough) around that time. She is up to date on her vaccines, including Covid-19 vaccination, having received her third dose 2 months ago. Testing for SARS-CoV-2 is negative.

Physical examination reveals a heart rate of 116 beats per minute, a blood pressure of 110/70 mm Hg, a respiratory rate of 18 breaths per minute, and an oxygen saturation of 98% while the patient breathes ambient air. Her breath sounds are difficult to auscultate because her pain is causing her to take shallow breaths. She has a normal first heart sound, a split second heart sound, a 2/6 vibratory systolic murmur heard at the left midsternal border, and a rub. Her chest pain is not reproducible with palpation over costochondral junctions. She has no hepatomegaly or peripheral edema.

A chest radiograph is normal. An electrocardiogram is obtained (figure).

Which one of the following medications is most important to initiate in this patient?

Calcium-channel blocker
Anticoagulant
Nitroglycerin
Nonsteroidal antiinflammatory drug
Glucocorticoid

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