CASE REPORT
Extensive Pneumomediastinum in a 20-Year-Old By Nancy W. Weber, DO, FACOEP, FACEP, MBA
Vice Chair for Quality and Patient Experience, Texas Tech University Health Sciences Center at El Paso
A 20-year-old female presented “emergently” from an Urgent Care complaining of nausea, vomiting, diarrhea and facial swelling with crepitus. She presented to a Midwestern Community Hospital with an EM residency associated with a large academic university, and with several tertiary referral centers in a 60-90 mile radius.
her esophagus, and to her throat. She has a sensation of fullness, and it hurts to take a deep breath and to swallow, but not to talk or breathe. She denies fever, chills, dizziness, dehydration or other systemic signs or symptoms beyond what was noted above. Her mom notes that her voice sounded like it did before she needed a tonsillectomy and adenoidectomy.
She had intractable nausea, vomiting and diarrhea since waking, and several hours later she felt and heard a “pop.” Shortly thereafter, her boyfriend noticed some right sided facial swelling. It is now on her bilateral face, and has spread to her neck and proximal/mid chest over the past few hours.
PHYSICAL EXAM
She complains of a burning raw feeling of pain from her stomach to
General: She appears moderately anxious and in mild distress, otherwise healthy, non-toxic, and well appearing. Skin: Warm, dry, normal color, no rash, with palpable crepitus in the neck and anterior chest; can visualize fullness/swelling in the face but no skin irregularities on the face or torso.
Eyes: Pupils equally round, extraocular movements intact, clear conjunctiva, normal sclera. HEENT: Normocephalic atraumatic, moist mucous membranes, bilateral moderate cheek fullness. Neck: Mildly tender to palpation, supple without nuchal rigidity, mild fullness, full range of motion. Pulmonary: Clear to auscultation without wheezes, rhonchi or rales, no accessory muscle use, no stridor, normal excursion. Cardiovascular: Regular rate and rhythm with normal heart sounds and without murmurs. Gastrointestinal: Soft, non-tender, non-distended, normal bowel sounds, no crepitus. Lymphatics: No edema in lower extremities. Musculoskeletal: Extremities are non-tender and have no gross deformity, redness or swelling. Neurologic: Alert and oriented x 3, GCS 15, normal mentation and speech, stable gait (as seen ambulating to the bathroom). Psychiatric: Normal except as noted previously, clear and linear thought process. Differential diagnosis: Pneumomediastinum consistent with Mallory Weiss tear; rule out Boerhaeve’s, will empirically treat with antibiotics, get Xrays (XR), CT’s, IV fluid rehydration, control nausea, consult as needed.
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EMpulse Summer 2020
