Today, the patient complains of acute onset and persistent chest pain associated with dysphagia and pain upon flexing his neck. His blood pressure is 115/70 mm Hg, heart rate of 101 beats per minute, respiratory rate 18 breaths per minute, and oxygen saturation of 97% on room air. As you listen to his heart, you hear a crunching sound. His abdomen is soft with mild epigastric tenderness. The ECG is sinus tachycardia without ST-T wave abnormalities. On chest x-ray, there is air in the mediastinum.
What is the most likely diagnosis?
a.Acute coronary syndrome (ACS)
b.Pancreatitis
c.Alcoholic ketoacidosis
d.Esophageal perforation
e.Aortic dissection
The right answer is D
Explanation:
Esophageal perforation is
potentially life-threatening conditions that can result from any valsalva-like maneuver, including childbirth, cough, and heavy lifting. Alcoholics are at risk due to their frequent vomiting. The most common cause of esophageal perforation is from iatrogenic causes such as a complication from upper endoscopy. The classic physical exam finding is mediastinal or cervical emphysema. This is noted on palpation of the chest wall or by a crunching sound heard on auscultation, also known as Hamman’s sign.
(a) The patient has no ST-T wave abnormalities on ECG. The history and physical exam are not consistent with ACS. (b)Alcoholics have a high incidence of pancreatitis and can present with epigastric tenderness, however they usually don’t have mediastinal air on radiography. (c) Alcohol ketoacidosis usually occurs in a heavy alcohol user who has temporarily stopped drinking and eating. Aortic dissection (e) usually occurs in patients with chronic hypertension or connective tissue disorders. They
should not have Hamman’s sign.
