 You're working in the emergency department. A patient presents with severe abdominal pain. On the triage note, he is tachycardic and hypotensive. You quickly started to resuscitate this patient. You move them into the monitored area with cardiac monitoring. You've instructed the nurse to start two large borough IVs and start to give him two liters of crystalline fluid. Blood work is also ordered at this point. You also ordered something for the patient's pain. When you talk to the patient, he says that his pain is mostly in the upper part of this abdomen. It is certain abruptly and severely. The pain is constant with no aggravating or alleviating factors. There's no associated vomiting or diarrhea. There's also no chonos of breath, chest pain or diaphoresis. The patient does not drink or smoke. The only medication he takes is apiprofen every day for muscle ache for the past year. As we examine him after the two liters of crystallite bolus, his heart rate has gone down and his blood pressure has gone up. When you examine his abdomen, you see that his abdomen is rigid and he does not want to move. There's severe tenderness all throughout his abdomen. There is involuntary guarding and rebound tenderness throughout his abdomen as well. The bowel sounds are decreased. You decide to order a portable upright chest x-ray. On examination of the x-ray, you saw free and under the diaphragm. You diagnose the patient with a perforated viscous. You start the patients on IV antibiotics, give him more analgesics and call the on-call surgery team for management of this patient.