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  #1  
Old 05-25-2011
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X Ray Look at the chest x-ray...what do you think?

After eating a piece of meat the patient began vomiting and developed severe chest pain. Here is the chest x-ray.

Look at the chest x-ray...what do you think?-chest1.jpg
click the image to enlarge

The patient has:

A) SARS.
B) A ruptured esophagus.
C) An acute myocardial infarction.
D) Aspirated the piece of meat.
E) A ruptured aortic aneurysm.
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  #2  
Old 05-25-2011
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I don't think they ask such questions in the USMLE Step 1 exam.

You have to tell us more about the patient background.

You won't be ask to make a diagnosis based on a chest X ray image only, they don't do that even in the CK or Step 3 exam.
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Old 05-25-2011
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the history is more than enough to know the diangosis...but maybe the qs is to hard for step 1...
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Old 05-25-2011
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Is it b???
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Old 05-25-2011
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I think its e coz aortic aneurysm may cause such mediastinal widening ass seen here .. And aortic aneurysm may rupture and present such presentation
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Old 05-25-2011
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Quote:
Originally Posted by bebix View Post
After eating a piece of meat the patient began vomiting and developed severe chest pain. Here is the chest x-ray.

Attachment 1324
click the image to enlarge

The patient has:

A) SARS.
B) A ruptured esophagus.
C) An acute myocardial infarction.
D) Aspirated the piece of meat.
E) A ruptured aortic aneurysm.
The answer here is esophageal rupture.. the question and X-ray is enough to answer this.. Eating meat is no significant in particular, just eating, followed by vomiting, and acute chest pain, with pleural effusion and subcut. emphysema on X-ray.. all are classical features of esophageal rupture..
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  #7  
Old 05-25-2011
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Quote:
Originally Posted by MTBCK View Post
The answer here is esophageal rupture.. the question and X-ray is enough to answer this.. Eating meat is no significant in particular, just eating, followed by vomiting, and acute chest pain, with pleural effusion and subcut. emphysema on X-ray.. all are classical features of esophageal rupture..
YES!

the answer is esophageal rupture

There are two findings in this case that should make you think of a ruptured esophagus. They are: air in the mediastinum (streaky air seen just to the right of the upper thoracic spine) and a left pleural effusion. That combination - mediastinal emphysema and a left pleural effusion - especially in someone who has been retching or vomiting, is strongly suggestive of a tear in the esophagus, usually in its distal portion.
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  #8  
Old 05-25-2011
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The only thing we know from the history is that this patient just ate meat and now has symptoms + consolidation on an x-ray

The only answer I could think of is D, aspiration of a piece of meat leading to airway obstruction

SARS- Nothing would indicate this from the history
Ruptured Esophagus- No indication of blood in the vomit
Acute MI- Possible, but not likely because the pain is not said to be radiating or crushing. Would expect a more detailed description of pain if it were MI
Ruptured AAA: Not likely to be caused by eating a meal
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  #9  
Old 05-25-2011
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haha guess I was wrong
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Old 05-25-2011
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Quote:
Originally Posted by apx85 View Post
The only thing we know from the history is that this patient just ate meat and now has symptoms + consolidation on an x-ray

The only answer I could think of is D, aspiration of a piece of meat leading to airway obstruction

SARS- Nothing would indicate this from the history
Ruptured Esophagus- No indication of blood in the vomit
Acute MI- Possible, but not likely because the pain is not said to be radiating or crushing. Would expect a more detailed description of pain if it were MI
Ruptured AAA: Not likely to be caused by eating a meal
"Ruptured Esophagus- No indication of blood in the vomit"...the classic history of esophageal rupture is one of severe retching and vomiting followed by excruciating retrosternal chest (not blood in the vomit)...but I have to say that I thought the answer was E)
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Old 05-25-2011
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typical picture of Boerhaave Syndrome
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  #12  
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Quote:
Originally Posted by beka-CTS View Post
typical picture of Boerhaave Syndrome
Is there any difference between esophageal rupture and Boerhaave syndrome?
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Old 05-25-2011
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Quote:
Originally Posted by eesfee View Post
Is there any difference between esophageal rupture and Boerhaave syndrome?
Boerhaave first described the spontaneous rupture of the esophagus in 1724. It typically occurs after forceful emesis. Boerhaave syndrome is a transmural perforation of the esophagus to be distinguished from Mallory-Weiss syndrome, a nontransmural esophageal tear also associated with vomiting.
Because it usually is associated with emesis, Boerhaave syndrome usually is not truly spontaneous. However, the term is useful for distinguishing it from iatrogenic perforation, which accounts for 85-90% of cases of esophageal rupture.
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  #14  
Old 05-25-2011
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Pneumomediastinum plus pleural effusion is rupture esophagus though not a step 1 question!
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  #15  
Old 05-26-2011
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Default emphysema

ermm... i want to ask how you diagnose emphysema on this patient?
because i can't see any or may be i dont know how to see...
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  #16  
Old 05-26-2011
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Quote:
Originally Posted by Kelvin View Post
ermm... i want to ask how you diagnose emphysema on this patient?
because i can't see any or may be i dont know how to see...
mediastinal emphysema?
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  #17  
Old 05-27-2011
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Default emphysema

i mean, what is the characteristic of emphysema in chest x ray?
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  #18  
Old 05-27-2011
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Quote:
Originally Posted by Kelvin View Post
i mean, what is the characteristic of emphysema in chest x ray?
This patient has mediastinal emphysema (aka pneumomediastinum), which is not the same as the "emphysema" that you see in a patient with chronic obstructive pulmonary disease.

here is another chest x ray. YouŽll see a radiolucent outline around the heart and mediastinum:
http://upload.wikimedia.org/wikipedi...stinum2008.jpg
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