Triage walks back a 45-year old Hispanic man with chest pain.  “He said ‘dolor’, and pointed right here,” says the triage nurse, indicating on himself a mid-sternal location.  “Good enough for me. I brought him straight back.”  Your Spanish is a little thin, but you get the high points – “nausea, vomito, mucho dolor,” the patient says, making good eye contact.  Physical exam shows P 70, BP 130/70, RR 22, sat 98% RA and tenderness in the epigastric region.  His cardio-pulmonary exam is normal, and the first 12-lead EKG is normal.

It’s a good story for angina, and from the primary nurse’s assessment, you gather that these are new symptoms.  Easy admission!  The usual diagnostics – including CXR, EKG and cardiac enzymes – are pending, and you order aspirin, morphine and anti-emetic treatment along with a fluid bolus.  A short while later the radiologist phones you (hey, it’s during the daytime).  “You know,” he starts out between sips of espresso, “I’m not entirely sure about this chest X-ray.  There might be a little air in the mediastinum.  If it’s alright with you, I’ll ask the radiology techs to drop off a little gastrografin down there.”  Sure, you think, no problem. I’ve got other fires to fight.  “Let me know what you find,” you quip back.

A short while later you review both the CXR and the gastrografin swallow.  What do they show?  What comes next?