A 74-old-woman presents the the Emergency Department (ED) with severe abdominal pain and nausea over the past 30 hours. She describes the pain as sharp yet diffuse, being unable to localize it further. When the pain initially began, she thought it was due to 'heartburn,' which she indicates she has had regularly for years. Usually her pain begins following meals, and can last for several hours. The pain has caused her to eat less at mealtimes. She estimates a 10 lb. weight loss over the past 3-4 years. The patient's current episode was not related to eating, and it became more severe. For the latter two reasons, and because the pain persisted to a second day, she called her daughter, who convinced her to come to the ED.

The patient's past medical history is significant for coronary artery disease and congestive heart failure, diagnosed 8 years previously. Her medications include a 'heart pill' and a 'water pill,' both of which she takes regularly as prescribed. She describes having dyspnea and angina when she overexerts herself; however, she has been able to carry out her activities of daily living with some adjustments. She lives alone at home.

General Appearance: The patient is alert, but is occasionally gasping in pain, made worse when sitting upright. Blood pressure is 110/70, heart rate is 95 and somewhat weak, and respiratory rate is 24. Temperature 101.0 °F. The patient is 5'5" tall, and weighs approximately 170 lbs. Other pertinent physical findings are as follows:

Abdominal: Soft, with no guarding or rebound on palpation. Bowel sounds present. Dullness to percussion noted over the flanks peripherally; positive fluid wave present. Mild hepatomegaly present.

Cardiovascular: Mild jugular venous distension present. An S3 is appreciated.

Musculoskeletal: Pitting edema (2+) up to mid-calf level.

Pulmonary: Rales heard over both lung bases.