USMLE Step3 Question of the Week #492

#492.  A 37-year-old woman with a history of bulimia nervosa presents with chest pain. Patient describes it as a sharp pain, localized to the middle of the chest, and occurred acutely last night after vomiting.  Current medications are fluoxetine 60 mg orally daily and a daily multivitamin.

On physical exam, patient appears ill and diaphoretic.  Vital signs show temperature of 37 °C (98.6 °F), blood pressure of 135/85 mm Hg, pulse of 90 /min, respiratory rate of 30 / min, and oxygen saturation of 98% on room air.  Oropharynx is erythematous, dentition is poor and back molars show significant erosion.  There is dullness to percussion and diminished breath sounds over the lower lobe of the left lung.  Remainder of the physical exam is normal.   EKG and laboratory tests are normal.  Chest x-ray shows a small left pleural effusion and evidence of pneumomediastinum.

Which of the following is the definitive diagnostic step in this patient?

A. Esophagogastroduodenoscopy

B. Barium swallow study

C. Helical CT of the chest without contrast

D. Gastrografin swallow study

E. Thoracentesis



4 Responses

  1. D

  2. D is the study of choice. The gastrograffin dye is water soluble, but radiopaque .

  3. This question is assessing the causes of pneumomedistinum. The most common causes are esophageal rupture(boorhave syndrome), alveolar rupture with acute sever asthma attack and bowel perforation with escaped air spreading into the chest cavity. Based on the patients history of bulimia and symptoms and signs of repeated vomiting, excessive retching and vomiting is the most likely cause of patients sudden onset chest pain due to esophageal rupture and pneumomedistinum. CT helical scan will only confirm the diagnosis with greater detail. The next best step would be thoracentesis for the pleural effusion.

  4. D gastrografin swallow

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