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.
•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.
–WBC 7.9 x 109/L;
–platelets 226 x 109/L.
•Liver function tests are normal.
•Clotting profile is normal.
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).