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Answer 1
  1. Administer an NSAID. The patient’s clinical history is consistent with acute pericarditis, likely viral in nature. The ECG supports this diagnosis, with findings of PR-segment depression as well as concave ST-segment elevation in a large territory that does not follow a coronary artery distribution (Figure 1). An NSAID should be administered to alleviate the patient’s chest discomfort.1 Atrial fibrillation was incidentally found on physical examination at the time of presentation. Atrial fibrillation is not an uncommon finding in patients with pericarditis and may resolve on its own after the inflammatory process subsides.1,2 The use of anticoagulation in this young woman with no significant risk factors for stroke or thromboembolism would be of little benefit, and it may be harmful given that the patient might have a pericardial effusion associated with pericarditis, which can be worsened by anticoagulation.2 The patient is not experiencing an acute MI; therefore, IV thrombolytic therapy and aspirin and cardiac catheterization are not indicated.

    1. Lange RA, Hillis LD. Clinical practice. Acute pericarditis [published erratum appears in N Engl J Med 2005;352:1163]. N Engl J Med 2004;351:2195–202.

    2. Fuster V, Ryden LE, Cannom DS, et al; European Heart Rhythm Association; Heart Rhythm Society. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation—executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients with Atrial Fibrillation) [published erratum appears in J Am Coll Cardiol 2007;50:562]. J Am Coll Cardiol 2006;48:854–906.

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