radER Case 13.1





Case 1 Questions

54 YOM presents to emergency department complaining of midsternal chest pain that he states has been coming and going for the past few years.  He states it has worsened over the past week becoming more constant.  He denies exertional component to his chest pain.  He denies any shortness of breath or difficulty breathing.  He does state that he intermittently feels nauseated but does not have any episodes of emesis.  He denies any fevers, chills, and productive cough.  He states that he has a history of hypertension, diabetes, and coronary artery disease with CABG x3.

The patient’s physical examination is unremarkable.

1. What significant abnormality is noted on the PA view of his patient’s chest film?
A. Acute Infiltrate
B. Increased Pulmonary Vascular Congestion
C. Esophageal dilatation
D. Westermark Sign

2. What is the most preferred initial screening/diagnostic test if the above condition is suspected?
A. Barium Swallow
B. CTA Thorax
C. D-Dimer
D. Echocardiogram

3. What is the preferred initial pharmacotherapy?
A. Heparin bolus with subsequent heparin ggt
B. Calcium Channel Blockers or Nitrates
C. Cetriaxone and doxycycline
D. Fondaparinux with warfarin overlap

Case 1 Answers

1. Correct Answer C. Esophageal dilatation with air-fluid level is the most notable abnormality on the PA view of his chest x-ray. This is often seen in an advanced achalasia as the lower esophageal sphincter as constricted and not allowed any liquid or solids to pass causing significant dilatation of the esophagus. No acute infiltrate is noted in the chest x-ray to suggest pneumonia.  No increased pulmonary vascular congestion is appreciated. Pulmonary embolism should be considered however no shortness of breath or history of DVT/PE exists.  No Westermark Sign is noted on his chest x-ray.

2.  Correct Answer A. Barium Swallow is the preferred initial screening test if achalasia is suspected.  Extensive esophageal dilatation is typically only noted 1 chest x-ray in advanced cases. A CTA thorax is the preferred modality for diagnosis of acute pulmonary embolus.  A d-dimer should only be used in the low risk patient’s suspected of having a pulmonary embolus with a Well’s score of less than 2. An echocardiogram is also a good screening test for both acute pulmonary embolism with right heart strain as well as for acute heart failure however it serves no role in the diagnosis of achalasia.

 3.  Correct Answer B. Calcium Channel Blockers or Nitrates are the preferred initial pharmacotherapy for smooth muscle relaxation in patients with achalasia.  Ceftriaxone and doxycycline are preferred for patient’s being admitted with acute community acquired pneumonia. Heparin bolus with subsequent drip is preferred in patients with acute pulmonary embolus that may undergo PCI. Fondaparinux with Coumadin overlap is preferred for stable patient’s with acute pulmonary embolus.

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