• patient lies quietly (pain aggravated by movement and coughing)

• pale, sweating or ashen at first

• board-like rigidity

• maximum signs at point of perforation

• no abdominal distension

• contraction of abdomen (forms a 'shelf over lower chest)

• bowel sounds reduced (silent abdomen)

• shifting dullness may be present

• pulse, temperature and BP usually normal at first

• tachycardia (later) and shock later (3-4 hours)

• breathing is shallow and inhibited by pain

PR: pelvic tenderness

X-ray: Chest X-ray may show free air under diaphragm (in 75%)—need to sit upright for prior 15 minutes.

Limited Gastografin meal can confirm diagnosis.

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Dealing With Back Pain

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