The patient is a 16-year-old male who presents with difficulty breathing and pain in his throat, along with difficulty swallowing and pleuritic chest pain. All the symptoms began “a couple of hours” prior to presentation.
There is no history of trauma or choking, nor of a recent dental procedure.

On exam, the patient looks well, and is quiet and not toxic; there are no sign of distress. Pulse is 75, O2sat 94 and there is no fever. His chest is normal, with bilateral air entry, no wheeze or crackles.
Assessment is hindered by the patient’s inability to take deep breaths, however. His tongue, pharynx, and tonsils all appear normal.

View the x-ray taken (Figure 1) and consider what your diagnosis and next steps would be.
Resolution of the case is described on the next page.

Clinical Challenge: January, 2010

Nahum Kovalski, BSc, MDCM

Clinical Researcher at TEREM Emergency Services
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