View source for WBR0527

 {{WBRQuestion
|QuestionAuthor= {{M.P}}
|ExamType=USMLE Step 3
|MainCategory=Emergency Room
|SubCategory=Gastrointestinal
|MainCategory=Emergency Room
|SubCategory=Gastrointestinal
|MainCategory=Emergency Room
|SubCategory=Gastrointestinal
|MainCategory=Emergency Room
|MainCategory=Emergency Room
|SubCategory=Gastrointestinal
|MainCategory=Emergency Room
|SubCategory=Gastrointestinal
|MainCategory=Emergency Room
|SubCategory=Gastrointestinal
|MainCategory=Emergency Room
|SubCategory=Gastrointestinal
|MainCategory=Emergency Room
|MainCategory=Emergency Room
|SubCategory=Gastrointestinal
|Prompt=A 60 yr old male is brought to the emergency department.  He complains of vomiting and chest pain.  He says his symptoms started 2 hours ago when he was in a party with his friends.  He says he was drinking heavily and had a fight with his friend.  He vomited twice before the onset of chest pain and is worsening over the 2 hour.  The pain is radiating to the shoulders and is of 6/10 on severity scale.  His chest pain is aggravated on deep inspiration.  He denies any abdominal pain, bloody vomit, dizziness and black stools.  His is a known coronary heart disease patient and on medications for that. Otherwise his past history is insignificant.  His father died of myocardial infarction at the age of 60.  He occasionally smokes and drinks heavily when he is with his friends.  On examination pulse is 110/min, BP is 100/60 mmHg and SpO2 is 94%.  Chest examination reveals S3, decreased breath sounds and dullness on percussion on left side.  Abdomen is mildly distended and there is epigastric tenderness.  What is the most likely diagnosis?
|Explanation=Effort rupture of the [[esophagus]] or [[Boerhaave syndrome]] is a spontaneous [[perforation]] of the esophagus that most commonly results from a sudden increase in intraesophageal pressure combined with negative intrathoracic pressure caused by straining or vomiting.  The causes of spontaneous perforation include caustic ingestion, pill [[esophagitis]], [[Barrett's ulcer]], infectious [[ulcers]] in patients with [[AIDS]], and following dilation of esophageal [[strictures]].  Patients with Boerhaave's syndrome present classically with severe retching and vomiting followed by excruciating retrosternal chest and upper abdominal pain. Odynophagia, [[tachypnea]], [[dyspnea]], cyanosis, fever, and shock develop rapidly thereafter.  Physical examination is usually not helpful, particularly early in the course.  Subcutaneous [[emphysema]] (crepitation) is an important diagnostic finding but is not very sensitive, being present, a pleural effusion may be detected (decreased breath sounds and dullness on percussion). 
|AnswerA=Myocardial rupture



|AnswerAExp='''Incorrect''' : [[Myocardial rupture]] usually occurs after severe chest trauma like [[RTA]] and is unrelated to drinking and [[alcoholism]].
|AnswerB=Myocardial infarction

|AnswerBExp='''Incorrect''' : The patient history is more suggestive of esophageal rupture than [[myocardial infarction]].
|AnswerC=Esophageal rupture

|AnswerCExp='''Correct''' : Esophageal rupture most commonly results from a sudden increase in intraesophageal pressure combined with negative intrathoracic pressure caused by straining or vomiting.  It is usually associated with left sided [[pleural effusion]].
|AnswerD=Aspiration pneumonia

|AnswerDExp='''Incorrect''' : Conditions that predispose to [[aspiration pneumonia]] include reduced consciousness, dysphagia from neurologic deficits, disorders of the upper gastrointestinal tract including esophageal disease, surgery involving the upper airways or esophagus, and gastric reflux, mechanical disruption of the glottic closure or pharyngeal [[anesthesia]], and the recumbent position.
|AnswerE=Acute gastritis
|AnswerEExp='''Incorrect''' : Acute [[gastritis]] can present after heavy drinking with epigastric pain, but pleural effusion is unlikely.
|RightAnswer=C
|WBRKeyword=Boerhaave syndrome
|Approved=Yes
}}