History of Present Illness

A woman in her mid-50s presents to the emergency department with a history of nonradiating epigastric pain that began 36 hours ago. The patient notes that the pain has become more generalized today. She felt nauseous and tried to vomit and subsequently had a syncopal episode. She also felt she was going to have diarrhea several times but never did. She has had intermittent abdominal pain over the years for which she has taken omeprazole, but this current event “is different.” The patient denies any melena or hematemesis, fever or chills, or other complaints.

Vital Signs and Physical Examination

The patient’s vital signs are normal in the emergency department, but her blood pressure in the ambulance was 80/40 mm Hg prior to administration of normal saline (500 mL). Physical examination is otherwise normal except for diffuse abdominal tenderness with slight guarding. Initial diagnostic electrocardiogram shows no appreciable disease. Laboratory tests are normal except for mildly elevated troponin level (0.11 ng/mL). A computed tomography (CT) scan is ordered (Figure).

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