216.An 87-year-old woman with a history of dementia, arthritis, and
hypertension presents to the ED for abdominal pain. Her caretaker reports
that she is having mid-epigastric pain and had one episode of nonbloody,
nonbilious vomiting prior to arrival. The patient is oriented to name only.
Temperature is 99.8°F, HR is 110 beats per minute, BP is 80/44 mm Hg, RR
is 16 breaths per minute, and oxygen saturation is 96% on room air. On
examination, the abdomen is soft, nontender, with no masses, rebound or
guarding. Stool is brown and guaiac negative. You place two IV lines and
begin fluid resuscitation. You send her blood to the laboratory and order a
radiograph of her chest that is shown below. Which of the following is the
most appropriate next step in management?
220 Emergency Medicine
a. Start IV antibiotics
b. Order a CT scan of her abdomen
c. Call the surgery service
d. Place a central venous line
e. Discharge home with Maalox