What investigations should be done for this patient?

Investigations for Patient Evaluation

The appropriate investigations for a patient should include complete blood count, biochemical tests (including C-reactive protein, blood gas analysis for base excess, and lactate), and imaging studies (neck, chest, and abdominal radiographs), with CT scan performed if perforation or complications are suspected. 1

Initial Laboratory Investigations

Blood Tests

• Complete blood count (CBC) 1
• C-reactive protein (CRP) 1
• Blood gas analysis for base excess and lactate 1
• Serum creatinine and electrolytes 1
• Liver function tests 1
• Blood glucose, hemoglobin A1c (if diabetes is suspected) 1

Additional Laboratory Tests

• Urine analysis (if urinary symptoms are present) 2
• Blood cultures (two sets) before antibiotic initiation if infection is suspected 1
• Cultures from any drainable collection 1

Imaging Studies

First-Line Imaging

• Plain radiographs of neck, chest, and abdomen to assess for:
  • Presence of radiopaque foreign bodies
  • Signs of perforation (free air)
  • Pleural effusions
  • Other abnormalities 1

Advanced Imaging

• CT scan should be performed if:

  • Perforation is suspected
  • Complications requiring intervention are suspected
  • Initial radiographs are negative but clinical suspicion remains high 1
  • The patient has systemic signs of infection or sepsis 1

• MRI may be considered in specific situations:

  • When CT is contraindicated
  • For better soft tissue evaluation 1

• Ultrasound can be useful for:

  • Evaluation of fluid collections
  • Guided drainage procedures 1

Special Considerations

For Suspected Esophageal Issues

• Biplanar radiography (including lateral projection) to differentiate between tracheobronchial and esophageal foreign bodies 1
• Avoid contrast swallow studies as they:
  • May delay other investigations
  • Risk aspiration in patients with complete obstruction
  • Can impair subsequent endoscopic visualization 1

For Suspected Infection/Abscess

• If abscess is suspected, imaging should guide drainage procedures 1
• Pus samples should be collected for culture in high-risk patients or those with risk factors for multidrug-resistant organisms 1

For Suspected Malignancy

• If malignancy is suspected, biopsy of the most accessible lesion 3
• CT scan of chest, abdomen, and pelvis 3

Clinical Pitfalls to Avoid

1. Delay in obtaining CT scan: Plain radiography has a false-negative rate of up to 47% for foreign bodies and up to 85% for food impaction, thin metal objects, wood, plastic, glass fragments, fish or chicken bones 1

2. Relying solely on normal laboratory values: Normal laboratory tests do not rule out serious pathology, especially in early presentations 1

3. Performing contrast studies in patients with complete obstruction: This increases risk of aspiration and may impair subsequent visualization 1

4. Delaying surgical intervention for imaging in hemodynamically unstable patients 1

5. Overlooking the need for blood cultures before starting antibiotics in suspected sepsis 1

By following this systematic approach to investigations, clinicians can efficiently diagnose the underlying condition and guide appropriate management decisions.