The overall incidence of diaphragmatic injury is 2.5 – 5% in

blunt abdominal trauma and 1.5% in blunt thoracic trauma [1]. Left sided injuries are substantially more frequent [1, 2]. However, bilateral injuries have also been reported [2]. Delayed diagnosis is not uncommon especially in the emergency room (ER) setting. Despite improvement in investigative techniques a significant amount of these injuries are overlooked. Associated injuries often shift diagnosis and treatment priorities towards other more life-threatening conditions. However, constant clinical surveillance and repeated evaluations of the patient are of paramount importance in order to minimize the likelihood of missing injuries with non-typical clinical presentation such as DR. click here Non-specific symptoms emanating from the respiratory system i.e. dyspnea often are the only clues for the diagnosis [3]. On the other hand, strangulation and perforation buy I-BET-762 represent the final devastating selleck consequences of the prolonged herniation of the abdominal organs into the chest [3]. Sometimes, a displaced nasogastric tube within the

left hemi thorax, a diagnostic sign in chest x-ray, establishes the diagnosis of DR in asymptomatic trauma patients [3, 4]. In the present report, we present a challenging case of a combined abdominal and head trauma patient. Repeated episodes of vomiting dominated on clinical presentation that on the absence of other clues shifted differential diagnosis towards a traumatic brain injury. However, a DR was finally diagnosed that justified the clinical symptoms. Case presentation A 32-year-old, unrestrained male driver was involved in head-on motor vehicle accident 4-Aminobutyrate aminotransferase at high speed. He was initially evaluated at the pre-hospital setting and was reported to be hemodynamically stable. On arrival, his score on the Glasgow Coma Scale was 15, blood pressure 110/75 mm Hg, pulse rate 100/min, and respiratory rate 17/min. The patent had a deep scalp laceration, signs of recent nasal bleeding and facial bruising suggestive of a high-energy head injury while he was also complaining of a

mild mid-epigastrium pain. On exam, the patient was alert and oriented. The chest wall was not tender to palpation. Auscultation of the chest wall did not reveal any pathology. The abdomen was non-distended, soft with mild tenderness however to palpation of the upper abdomen (mid-epigastrium). Motor and sensory function of all extremities was intact. The urine was grossly clear. Initial radiographic studies included a supine chest film that besides a widened mediastinum was generally inconclusive. Ultrasonography in the trauma unit did not show any abnormal fluid collection. The initial hematocrit value was 39.5% and blood gas pH was 7.37 with a base deficit of 3.8. Meanwhile the patient started complaining of nausea and several blood-spotted vomiting episodes were noted.