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A previously healthy 42-year-old male presented to the Emergency Department (ED) with a 3-day history of worsening abdominal pain. He felt nauseated and vomited twice. His pain started around the umbilicus, moved to the left side of his abdomen and then become generalized. It peaked the last few hours, and the painkillers did not work. His social history revealed that he was non-drinker, non-smoker and did not use any illicit drugs. The past and family histories were unremarkable. His blood pressure was 100/60 mmHg, pulse rate 120/min, the temperature 37.8°C (100°F), and respiration rate 24/min. Physical examination showed diffuse abdominal tenderness and voluntary guarding. Bowel sounds were not heard.
Bedside ultrasonography (USG) exhibited increased echogenicity of the peritoneal stripe, with corresponding horizontal reverberation artifacts over the liver. Plain chest radiographs confirmed the presence of free abdominal air. Oral intake was stopped, intravenous (IV) catheter was inserted, fluid therapy was started, and cefoperazone sodium was administered intravenously. Blood type and cross, complete blood count and coagulation were ordered. He transferred to the operation theater with the diagnosis of the perforated viscus.