USMLE Step 3 - Question 19

A 32 year old male with no significant past medical history presents to the emergency room with 3 hours of chest pain at rest. His blood pressure is 120/80, heart rate 80, and respirations 20. Physical examination is normal. Laboratory and a chest x-ray is normal. His ECG is below. Which of the following is the appropriate therapy?

A. Observation

B. Non-steroidal anti-inflammatory drugs

C. Corticosteroids

D. Emergent cardiac catheterization

This patient has pericarditis which can occur for many reasons including viral (usually after or during a URI), autoimmune, uremic, infectious (including tuberculosis), peri-MI (Dressler's or pericardial infarct), or iatrogenic (post-heart surgery). The ECG in question #19 is classic for pericarditis showing diffuse concave upward ST segment elevation in most leads, PR depression in most leads (may be subtle), and sometimes notching at the end of the QRS complex. PR elevation is seen in lead aVR (which always shows opposite findings). Treatment includes NSAIDs. Colchicine is second line and corticosteroids are used only as a last resort as they are thought to increase the risk of chronic pericarditis and constrictive pericarditis