Case 3

A 47 year old man with a history of alcohol excess is brought in by ambulance complaining of abdominal pain and vomiting for 24 hours.

His observations at initial assessment are:

• Pulse 138
• BP 197/89
• RR 18
• SaO₂ 96% on room air
• Temp 37.2^o

On questioning, the pain is ‘all over’, he has vomited food and some yellowish fluid but no blood. He has no diarrhoea or melaena - his bowels were last opened yesterday. He has not had any alcohol for the last 36 hours.

On examination he is in pain, writhing on the trolley. He is unkempt, with tar-staining of the finger and a strong smell of stale urine. He appears clinically dehydrated and is tremulous. There is no jaundice or obvious stigmata of chronic liver disease. His chest is clear and heart sounds normal. He has generalised tenderness of his abdomen and pushes you away as you try to test for rebound and guarding. He completely refuses a per rectum (PR) examination. You are not able to hear any bowel sounds on auscultation.

What actions would you take with this 47 year old patient?

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Scoring: Points are deducted for incorrect selections.

You receive his chest x-ray back. What does it show?

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