Respiratory distress and chest pain: a perforated peptic ulcer with an unusual presentation

We present a case report of a 54 year old man with respiratory distress and chest pain as the initial Emergency Department presentation of a perforated duodenal ulcer.We discuss an unusual presentation of a perforated duodenal ulcer that was recognized in the emergency department and treated promptly. The patient was surgically treated immediately, had a prolonged and complicated post-operative course, but is ultimately doing well. We also provide a brief literature review of the risk factors, imaging choices, and management decision required to treat a perforated ulcer.Perforated ulcers can have highly varied presentations and are occasionally difficult to diagnose in a complicated patient. Knowledge of the risk factors and a thorough history and physical can point to the diagnosis, but timely and appropriate imaging is often required because delays in diagnosis and treatment lead to poor outcomes. Early administration of antibiotics and immediate surgical repair are necessary to limit morbidity and mortality.Dyspnea and chest pain are common presenting complaints to the Emergency Department (ED), and they often occur concurrently. This combination of symptoms presents a diagnostic challenge for any physician given the broad differential each complaint entails. A thoughtful and judicious workup is required, and avoidance of anchoring on a particular diagnosis is necessary to avoid missing alternative, equally life-threatening possibilities. We present the case of a patient with perforated duodenal ulcer who initially arrived with respiratory distress and hypoxia.A 54-year-old white male presented to the Emergency Department with complaints of progressive dyspnea and chest pain that had started simultaneously with acute onset 10 h before arrival. He stated the chest pain started while going from a seated to standing position. The pain was substernal and sharp with epigastric radiation initally. The pain was also noted to be worse with movement, and although it was s