He describes moderate epigastric pain that has been present for the last two or three weeks. His past medical history is significant in that he was diagnosed as having a duodenal ulcer by endoscopy two years ago and took Cimetidine for one year. His other past medical history includes hypertension treated with Inderal and Hydro chlorothiazide. He smokes a pack of cigarettes a day. He drinks moderately although he admits up to three to four shots of vodka per day recently with a change of job.
Physical examination reveals a white male in severe distress.
The chest is clear. The abdomen is rigid with marked voluntary and involuntary guarding. No bowel sounds are present. The stool is guaiac negative. Admitting laboratory studies include a hemoglobin of 14, hematocrit 41, amylase 140.