5. Fishing for a Diagnosis

  1. James C. Pile4,
  2. Thomas E. Baudendistel5 and
  3. Brian J. Harte6
  1. Colin R. Cooke1,
  2. John V. L. Sheffield2 and
  3. Jan V. Hirschmann3

Published Online: 21 MAR 2013

DOI: 10.1002/9781118483206.ch5

Clinical Care Conundrums: Challenging Diagnoses in Hospital Medicine

Clinical Care Conundrums: Challenging Diagnoses in Hospital Medicine

How to Cite

Cooke, C. R., Sheffield, J. V. L. and Hirschmann, J. V. (2013) Fishing for a Diagnosis, in Clinical Care Conundrums: Challenging Diagnoses in Hospital Medicine (eds J. C. Pile, T. E. Baudendistel and B. J. Harte), John Wiley & Sons, Inc., Hoboken, NJ, USA. doi: 10.1002/9781118483206.ch5

Editor Information

  1. 4

    Departments of Hospital Medicine and Infectious Diseases, Cleveland Clinic, Cleveland, Ohio, USA

  2. 5

    Department of Medicine, Kaiser Permanente Medical Center, Oakland, California, USA

  3. 6

    South Pointe Hospital, Cleveland Clinic Health System, Warrensville Heights, Ohio, USA

Author Information

  1. 1

    Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan, USA

  2. 2

    Division of General Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA

  3. 3

    Division of General Medicine, Veterans Affairs Puget Sound Health Care System, University of Washington, Seattle, Washington, USA

Publication History

  1. Published Online: 21 MAR 2013
  2. Published Print: 15 MAR 2013

Book Series:

  1. Hospital Medicine: Current Concepts

Book Series Editors:

  1. Scott A. Flanders and
  2. Sanjay Saint

ISBN Information

Print ISBN: 9780470905654

Online ISBN: 9781118483206



  • chest pain;
  • differential diagnosis;
  • esophageal perforation;
  • fish bones


Esophageal perforation is an uncommon but life-threatening cause of chest pain that is difficult to diagnose because of its nonspecific symptoms. In most series, iatrogenic injury accounts for more than 70% of cases, whereas most of the other cases have spontaneous or traumatic causes. Perforation as a complication of ingesting fish bones, although rare, is well described and continues to be reported. Diagnosis of esophageal perforation secondary to a foreign body may be difficult because of the considerable overlap of symptoms with other causes of chest pain and failure to consider this infrequent condition in the absence of a classic history of retching. Incorrectly evaluating or failing to obtain essential data can lead to incorrect or delayed diagnoses. Positive likelihood ratios for history, exam, and bedside findings in life-threatening causes of chest pain are listed in this chapter.