December 2022: Something's Missing

​"Can I get a turkey sandwich?"I heard this exchange between a patient and a nurse. It's not an unusual request for patients experiencing homelessness. But this patient's chief symptom was that he couldn't eat. Something must be missing here.The patient confirmed to me that he wanted a turkey sandwich and that he had been losing weight because he couldn't eat. His loose pants requiring a new hole for his belt supported his words. Looking closer, I could see a left thoracotomy scar. He told me he had gotten it on his last hospitalization, but he had no idea why. Something was definitely missing here.Reviewing his record, I found that he had had an esophageal rupture requiring stenting. Looking at the portable chest x-ray, something certainly was missing here. The donut of truth revealed the answer. The esophageal stent had migrated to his stomach, significantly obstructing the pylorus. Now it was clear why the patient was hungry but couldn't eat. And it was clear what was missing on the chest x-ray: the stent. ​Reviewing the initial radiograph, the displaced tube could be seen lying obliquely with the tip just left of midline below the diaphragm. The wayward tube was removed by gastroenterology. The patient finally got his turkey sandwich.Tip To Remember: Sometimes when the story doesn't make sense, it is because a critical piece is missing, and that can be revealed with a little extra attention and time.Tags: Esophageal rupture, stent, x-ray, g...
Source: Lions and Tigers and Bears - Category: Emergency Medicine Tags: Blog Posts Source Type: blogs