Indigestion

Happy New Year! Here is the first case of 2015. 

A 51yo male with history of GERD is brought in by advanced life support ambulance for severe abdominal pain. Paramedics report the patient appeared diaphoretic on arrival, otherwise has maintained stable vital signs in transit. The patient describes the pain as radiating to his back with associated shortness of breath and states it is "the worst pain of my life." He denies having any nausea or vomiting. On further questioning he endorses a history of multiple endoscopies in the past for his GERD, the most recent being 3 years ago. He took Prilosec this morning before eating a breakfast of oatmeal and bacon after which he felt like something was stuck in his throat with onset of severe pain. 

On exam the patient is a well-nourished middle-aged male, diaphoretic, in moderate distress and clutching his chest. He has clear breath sounds bilaterally. Normal heart sounds. His abdomen is soft and tender in the epigastrium without rebound or guarding. 

ECG shows sinus tachycardia without signs of ischemia. Laboratory tests are pending. The patient's pain mildly improves with 1 mg IV Dilaudid given twice. You decide to order a CT scan of the patient's chest which is shown below: 

What is the diagnosis?

Please leave a comment below and share with us how you would manage this patient.

The diagnosis for this case will be posted in approximately 1 week.