Question

A 33-year-old man with a history of alcohol abuse and cirrhosis presents to the emergency department with profuse vomiting. The patient is aggressive, combative, emotionally labile, and has to be chemically restrained. The patient continues to vomit and blood is noted in the vomitus. His temperature is 99.2°F (37.3°C), blood pressure is 139/88 mmHg, pulse is 106/min, respirations are 17/min, and oxygen saturation is 100% on room air. The patient complains of sudden onset chest pain during his physical exam. A crunching and rasping sound is heard while auscultating the heart. Which of the following is the pathophysiology of the most likely diagnosis?

a. Dilated and tortuous veins
b. Inflammation of the pericardium
c. Mucosal tear
d. Pericardial fluid accumulation
e. Transmural tear

Answer 1

The patient's symptoms, including a crunching and rasping sound heard during auscultation and sudden onset chest pain, suggest Boerhaave syndrome, which is characterized as a transmural tear of the esophagus, often related to vigorous vomiting.

Step-by-step explanation:

The most likely diagnosis given the symptoms of a crunching and rasping sound while auscultating the heart, along with sudden onset chest pain in the context of a pre-existing condition of cirrhosis and profuse vomiting is Boerhaave syndrome, which involves a transmural tear of the esophagus. Boerhaave syndrome is a severe, spontaneous tear of the esophagus that results from violent retching or vomiting.

The association of blood in the vomitus (hematemesis) suggests that there has been a significant tear into the blood vessels as well. The typical presentation includes chest pain and subcutaneous emphysema, which manifests as a rasping sound, known as Hamman's sign, heard during auscultation when air enters the mediastinum and potentially the pericardium.