title: Respiratory distress and chest pain: a perforated peptic ulcer with an unusual presentation.
abstract: BACKGROUND
  Dyspnea and chest pain are common presenting complaints to the ED, and coupled together can present a challenging diagnostic dilemma in patients in extremis. A thoughtful evaluation is required, giving due diligence to the immediate life threats as well as multiple etiologies which can cause serious morbidity. A perforated peptic ulcer is one such possibility and requires rapid diagnosis and prompt intervention to avoid the associated high risk of morbidity and mortality.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Uniformed Services University of the Health Sciences, Bethesda, MD, USA. David.Bruner@med.navy.mil.
authors.forename: David I
authors.initials: DI
authors.lastname: Bruner
authors.forename: Corey
authors.initials: C
authors.lastname: Gustafson