A 64-Year-Old Man Comes to the Emergency Department with Sudden

question 81

Multiple Choice

A 64-year-old man comes to the emergency department with sudden onset of epigastric abdominal pain and vomiting.  He attended a colleague's retirement party the night before and admits that he had "a little too much to drink."  The patient vomited twice when he got home and noticed abdominal pain after the second vomiting episode.  He thought the pain was related to "heartburn" and took extra-strength calcium carbonate antacids with little relief.  He tried to sleep, but the severe pain kept him awake.  The patient has a history of hypertension and takes amlodipine.  He is a current smoker with a 40-pack-year history.
His temperature is 38.0° C (100.4° F) , blood pressure is 108/64 mm Hg, pulse is 110/min, and respirations are 18/min.  Pulse oximetry is 96% on room air.  Examination shows a man in moderate distress.  There are normal first and second heart sounds.  Decreased breath sounds are heard on the left lower lung field with dullness to percussion.  There is both right upper-quadrant and epigastric tenderness without rebound or guarding.
Chest x-ray reveals pneumomediastinum and a moderate-sized left pleural effusion.
Which of the following is the best next step in managing this patient?

• A)Abdominal ultrasound
• B)Chest tube placement
• C)Contrast esophagography
• D)Esophagogastroduodenoscopy
• E)Serum amylase and lipase

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