Approach to pneumoperitoneum and peritonitis (perforated viscus) Quiz: Ace Your Exams

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A 66-year-old man presents to the emergency department for evaluation of worsening abdominal pain, nausea, and vomiting for 3 days. The patient reports that he was treated 10 days ago as an outpatient with antibiotics for acute diverticulitis. The patient states that the pain initially began in the left lower quadrant, however now is felt throughout the entire abdomen. The patient states that encountering bumps in the road en route to the emergency department made the pain worse. Temperature is 39 ºC (102.2 ºF), pulse is 106/min, blood pressure is 133/77 mmHg and respirations are 18/min. The patient appears uncomfortable lying supine on the stretcher. An upright chest radiograph is obtained and is shown below. Which of the following examination findings is most likely to be present?

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Arrest of inspiration with deep palpation of the right upper quadrant

Abdominal distention, diffuse tenderness, and rebound pain

Absent cremasteric reflex

Abdominal bulge with Valsalva maneuver

Pain out of proportion to the physical examination findings