goodduck

PPU

[highly suspected]
1. elderly, NSAID
2. history of peptic ulcer
    L:  epigastric pain
    P:  subacute/chronic dull epigastric pain after meal(3~4hr)

1.  Stage of Prostration (primary shock):
L:  epigastric pain -> entire (diffuse)abdomen ; suprapubic region
Q: excruciate, even syncope/collapse
Q: minutes to two hours
O: acute, sudden
A:  N/V, retch; diaphoretic, hypothermia, hypotension -> sympathetic

# tachycardia, weak pulse, cool extremity 

2. Stage of Reaction ( mimic getting better)
L:  generalized abd pain; both shoulder -> ant.perforation ;  Rt. shoulder -> pylorus or duodenum ; back -> post. perforation
Q: pain persistent, but lessen in intensity
O: two hrs to 12 hrs

# RUQ liver dullness diminish (free air)
# rectal examnination -> pelvic peritoneum tenderness

3. Stage of Frank peritonitis
"advanced peritonitis"
abd pain, rigidity, tenderness decrease

# facies hippocratica
# temperature decrease (subnormal) ?