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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