22

Case 22


History



A 88-year-old gentleman from a nursing home is brought to the accident and emergency department after ingestion of a foreign body. The caregiver suspects he had swallowed a five dollar coin (Figure 22.1). He subsequently develops chest pain and epigastric discomfort hours after ingestion. He has a past history of hypertension, diabetes mellitus and dementia.






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Physical examination


Afebrile, pulse 94 bpm, BP 160/80mmHg, SaO2 98% on RA.


Hydration is satisfactory.


Examination of the hands reveals no clubbing and normal-appearing palmar creases.


Head and neck examination is unremarkable.


Cardiovascular: HS dual, no murmur.


His chest is clear on auscultation, with no stridor. He is not in respiratory distress.


Abdominal examination reveals a soft abdomen, with no tenderness/guarding/rebound tenderness. Bowel sounds are normal.


No signs of oedema.


Investigations


CBC:


WBC 7.9 x 109/L;


haemoglobin 13g/dL;


platelets 226 x 109/L.


Liver function tests are normal.


CRP normal.


Clotting profile is normal.


What other physical examinations would you like to perform?


A complete neck exam looking for erythema, tenderness, swelling or crepitus should be performed. If crepitus is present it would be suggestive of subcutaneous emphysema and raises the suspicion of a perforated viscus.


What further investigations would you request?


Radiographs would be useful for localisation and screening for complications, such as free gas under the diaphragm or mediastinal gas.


A lateral radiograph of the neck together with a chest X-ray are performed (Figure 22.2).






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Oct 23, 2019 | Posted by in GASTROENTEROLOGY | Comments Off on 22
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