CC: A 60 yo Abe Simpson (father of homer) with a past medical history of htn and anxiety presents to your ED for severe epigastric abdominal pain…
HPI: While straining during a bowel movement earlier, the patient suddenly vomited – large volume, non-bloody, nonbilious. After vomiting, he had sudden onset of severe epigastric pain, radiating to the chest, lightheadedness, anxiety, and dyspnea. After ten minutes without improvement, he calls 9-11 and comes into your ED. His symptoms continue to be constant and severe.
He denies chest pain, cardiac disease, pe or dvt risk factors, change in exercise tolerance, and any symptoms before the incident.
Vital Signs: 147/72, HR 102, RR 25, temp 98.9, o2 sat 92% on room air
PE: obese male anxious in distress.
Cardiac- normal pulses no JVD, normal S1,S2
Pulm- decreased L base, tachypnic, difficult to auscultate.
Abd- obese, soft, nondistended, mild epigastric tenderness, + Bowel sounds
After IV access and oxygen, the ECG is unremarkable and you send off a full set of labs.
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CXR
On re-evaluation after morphine, esomeprazole, and odansetron, he actually looks worse.
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Answer the following questions for a chance at a BIG prize.
1. What are you top 3 differential diagnoses?
2. What tests or treatments will you perform next?
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By Dr. Carl Alsup and Dr. Andrew Grock
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andygrock
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2 Comments
dzeccola · February 6, 2015 at 10:34 pm
Differential:
1) Incarcerated Paraesophageal Hiatal Hernia
2) Myocardia Infarction
3) Boerhaave Syndrome
Tests and Treatment:
1) Supplemental O2
2) CT of the Chest
3) Analgesia
4) Emergent Surgical Consultation
edenkim · February 8, 2015 at 4:58 pm
the patient is rotated, but it does appear like there is tracheal deviation to the right and a lack of lung markings along the periphery on the left with a clear border, concerning for tension pneumothorax, especially given the patient’s dyspnea, tachypnea, decreased O2 sat, and decreased breath sounds in left lung base
Ddx:
1) tension PTX
2) boerhaave syndrome
3) MI
Tx:
1) needle decompression at 2nd intercostal space or finger thoracostomy
2) O2
3) morphine for pain
4) chest tube for definitive management
5) gastrograffin esophagram or CT chest
6) surgical consult
7) vanc and zosyn for broad spectrum coverage if imaging positive for esophageal rupture
8) keep NPO