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JAMA Clinical Challenge

Acute Onset of Retrosternal and Epigastric Pain

Image of lateral chest radiograph

Heather A. Osborn, MD
Blake C. Papsin, MD
A 15-year-old previously healthy male presents to the emergency department with acute onset of severe pleuritic retrosternal and epigastric pain after swallowing a mouthful of cold soda. He has no previous surgeries or major illnesses, no history of trauma, and no recent emesis. Following the onset of pain he waited several hours and ate 4 chili dogs before presenting to the emergency department. Findings from a general physical examination revealed a healthy, well-appearing young man with mild epigastric tenderness but an otherwise benign abdomen and stable vital signs. A lateral chest radiograph (Figure) revealed a small amount of pneumomediastinum, and a soft tissue lateral neck radiograph revealed retropharyngeal and paratracheal air. Radiography was followed by performance of a computed tomography scan in the emergency department.

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Author Affiliations: Drs Osborn (h.osborn@utoronto.ca) and Papsin are affiliated with the Department of Otolaryngology—Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.