A 65-year-old man presents to the emergency department with sudden-onset severe upper abdominal pain. The patient reports that the pain began abruptly 8 hours ago while resting. It is severe, constant, and localized to the upper abdomen but radiates to his right shoulder. He also feels nauseous but has not vomited. He has a history of intermittent epigastric pain for the past year, often relieved by over-the-counter antacids. Recently, he started taking ibuprofen daily for knee pain. Past Medical History: •Peptic ulcer disease (diagnosed 2 years ago). •Hypertension, managed with lisinopril. Medications: •Ibuprofen, 400 mg twice daily (started 1 month ago). •Lisinopril, 10 mg daily. Social History: •Smoker: 20 pack-year history. •Occasional alcohol use. Physical Examination: •Vital signs: BP 90/60 mmHg, HR 115 bpm, Temp 99.8°F, RR 22/min. •General: Appears distressed and in significant pain. •Abdomen: •Rigid with diffuse tenderness, particularly in the epigastric region. •Positive rebound tenderness and guarding. •Absent bowel sounds. Laboratory Findings: •White blood cell count: 18,000/mm³ (elevated). •Hemoglobin: 12.8 g/dL (normal). •Serum amylase/lipase: Normal. •Liver function tests: Normal. Which of the following imaging findings would confirm the diagnosis of a perforated peptic ulcer?

A 58-year-old man presents to the emergency department with sudden onset of severe upper abdominal pain radiating to his right shoulder. He reports that the pain started abruptly 6 hours ago. He has a history of long-term NSAID use for chronic back pain. On examination, his abdomen is rigid with tenderness and guarding. His vital signs show BP 90/60 mmHg, HR 110 bpm, and Temp 100.2°F. What is the most likely diagnosis?

After confirming a diagnosis of Boerhaave syndrome via imaging in a 60-year-old male who presented with symptoms after vomiting, the team discusses management strategies. What is the definitive management for Boerhaave syndrome?

A 50-year-old man presents to the emergency department after an episode of severe vomiting following a heavy meal. He now complains of severe chest pain, shortness of breath, and subcutaneous emphysema around his neck. His vital signs show tachycardia. Which of the following is the most likely diagnosis?

A 55-year-old male with a history of heavy alcohol use presents with retrosternal chest pain and difficulty breathing after repeated episodes of vomiting. Physical examination reveals tachycardia, hypotension, and subcutaneous crepitus. Chest X-ray shows pneumomediastinum, and a diagnosis of Boerhaave syndrome is confirmed. What is the most common location of the esophageal rupture in Boerhaave syndrome?

A 42-year-old female presents to the emergency department with severe chest pain and dyspnea following forceful retching. She is hypotensive (BP: 85/55 mmHg), tachycardic (HR: 120 bpm), and febrile. Physical examination reveals subcutaneous crepitus over the chest and neck. A CT scan shows mediastinal air and fluid collection consistent with esophageal rupture. What is the most appropriate initial management for this patient?

A 50-year-old male presents to the emergency department with sudden onset severe chest pain after an episode of forceful vomiting following a heavy meal. He describes the pain as sharp and radiating to his back. On physical examination, there is subcutaneous crepitus over the neck and diminished breath sounds on the left side. Chest X-ray shows pneumomediastinum and left-sided pleural effusion. Which of the following investigations is the most definitive for diagnosing Boerhaave syndrome in this patient?

A 60-year-old female with a history of obesity presents with intermittent epigastric pain and regurgitation. Imaging confirms a paraesophageal hernia without signs of strangulation or volvulus. She is currently asymptomatic. What is the most appropriate initial management for this patient?

A 72-year-old male presents with progressive dysphagia and postprandial epigastric discomfort. He describes a “gurgling” sensation in his chest after meals. A chest X-ray shows an air-fluid level in the mediastinum. Which of the following diagnostic tests is most appropriate to confirm a paraesophageal hernia?

A 65-year-old female presents to the emergency department with acute chest pain, nausea, and postprandial bloating. She reports a history of intermittent heartburn and difficulty swallowing solid foods over the last year. Physical examination reveals mild epigastric tenderness. Which of the following is the most likely symptom caused by a paraesophageal hernia?