Elderly man with sudden, severe abdominal pain
A 72-year-old man is brought to the emergency department by his wife. He
complains of nausea, vomiting, and severe abdominal pain that makes it difficult
for him to walk. The pain began the previous afternoon and has worsened steadily.
The patient denies trauma and recent foreign travel. His history includes an appendectomy
performed many years earlier but is otherwise noncontributory.
Temperature is 37.7oC (100oF); heart rate, 127 beats per minute; respiration
rate, 26 breaths per minute; and blood pressure, 80/50 mm Hg. Except
for tachycardia and tachypnea, heart and lungs are normal. The abdomen is
moderately distended but soft; there is severe tenderness with guarding but
no rebound tenderness.
You order an abdominal radiograph. What abnormality does this film
reveal, and what further workup is required to arrive at a diagnosis?