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Vomiting & Chest Pain

UnFiNiShEd CaSe CoMe BaCk LaTeR

History of Present Illness: A man in his early 20’s presents to the emergency dept. for vomiting >20 times a day for 2 days and pleuritic midsternal pain for one day.  He denies abdominal pain, fever, diarrhea, bleeding or other complaints.  He denies any significant PMH or prior surgeries

Vital Signs & Physical Exam:

Vital signs are normal except for a pulse of 118

Physical exam is otherwise normal

Initial Diagnostic Testing:

  • CBC: normal except for WBC of 14.2 but with a normal CRP and Hb of 18.2
  • Chem 7: normal except for BUN/Cr of  33/1.4
  • Imaging: see CXR below

What is the most likely diagnosis?

  • A) PE
  • B) Pneumothorax
  • C) Pneumonia
  • D) Pleurisy
  • E) Pneumomediastinum

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ANSWER:

  • A) PE: typically can’t rule out or in with CXR
  • B) Pneumothorax: not seen
  • C) Pneumonia: PA CXR usually better for pneumonia but retrocardiac infiltrate better seen on lateral though not seen here
  • D) Boerhaave’s: usually presents with hemoptysis has a left pleural effusion
  • E) Pneumomediastinum: correct.  Pneumomediastinum is best seen on the lateral.  Note how the heart is outlined by a halo of dark air.

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