Clinical Challenge: Vomiting and Chest Pain in Young Man

History of Present Illness

A man in his early 20’s presents to the emergency department (ED) for evaluation of the recent onset of recurrent vomiting (>20 times/d) for the past 2 days. He also experienced pleuritic midsternal pain for the past 7 to 8 hours. The patient denies any abdominal pain, fever, diarrhea, bleeding, cough, shortness of breath, or other complaints. He also has no significant medical history or prior surgeries.

Vital Signs & Physical Examination

The patient’s vital signs are normal except for a pulse rate of 118 beats/min. His physical examination is otherwise normal including chest auscultation and examination of the abdomen. Initial laboratory tests show a normal complete blood count (CBC) except for a white blood cell count of 14.2 but normal CRP and Hb of 18.2 g/dL. Blood chemistry is normal except for BUN/Cr of 33 mg/dL and 1.4 mg/dL. Other labs are normal including the LFTs and lipase. A chest radiograph is ordered (Figure).