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A 55-Year-Old Man Comes to the Emergency Department Due to Sudden

question 450

Multiple Choice

A 55-year-old man comes to the emergency department due to sudden onset of retrosternal chest pain. The pain began 10 hours ago and has been mostly constant, although he describes it as "being bad and then getting a little better." The patient has had no lightheadedness, syncope, or shortness of breath. ECG shows normal sinus rhythm with 2-mm ST-segment elevation in leads V2 to V5. He is taken emergently for cardiac catheterization and undergoes percutaneous coronary intervention with stent placement to the left anterior descending artery. After the procedure, the ST-segment changes improve and he has complete resolution of the chest pain. On the third night, just prior to discharge, he calls for the nurse due to the sudden onset of sharp, retrosternal chest pain. The patient first noticed the pain while turning around in bed; it worsens with deep breathing. Temperature is 37.8 C (100 F) , blood pressure is 134/80 mm Hg, heart rate is 108/min, and respirations are 22/min. Physical examination reveals regular heart sounds and clear lung fields. There is a scratchy sound heard during ventricular systole along the left sternal border. Abdominal palpation reveals no localized tenderness. ECG shows sinus tachycardia with Q waves and T-wave inversion in leads V2 to V5.
Which of the following is the most likely cause of this patient's recurrent symptoms?

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