Chest pain after vomiting

A 66 year old man, previously fit and well, was admitted to the emergency department with sudden pain in his left chest and abdomen after vomiting. He had woken in the early hours of the morning, vomited three times, and started getting progressively worsening pain in the left side of his chest and abdomen, radiating to the shoulder. He was a non-smoker and occasional drinker. He had no history of operations or similar episodes.

On arrival he was pale, sweaty, clammy, and had fever. His pulse was 106 beats/min and regular. His blood pressure was 92/52 mm Hg. Jugular venous pulse and heart sounds were normal.

Trachea was central, and respiratory rate was 40 breaths/min. Left lung base was dull on percussion, and air entry was diminished. His abdomen was soft, with generalised tenderness and normal bowel sounds.

Full blood count, liver function tests, serum electrolytes and serum amylase were normal. His troponin I concentration was below 0.03 (normal range 0-0.1) ng/ml and the concentration of C reactive protein was less than 1 (<10) mg/l. Blood gas analysis showed mild metabolic acidosis, and an electrocardiogram showed sinus tachycardia. Attending doctors took an urgent x ray scan of his chest (fig 1) and a computed tomograph of his chest and abdomen (fig 2).