Dr. Jack Wittenberg: This was the first hospital admission of a 30-year-old man who complained of abdominal pain of 36 hours' duration. The pain began with a chilly sensation associated with diffuse abdominal discomfort which steadily increased. He had diarrhea for which he took kaolin mixture with pectin (Kaopectate) with minimal relief. On the morning of admission he awoke with increasing pain and was anorectic. By the time he came into the emergency ward, the pain was severe and steady, and had localized to the right of the umbilicus, and radiated into the right flank.
On physical examination, the patient's temperature was 102 F (38.9 C) and his pulse rate was 104 beats per minute. There was muscle spasm in the mid and upper abdomen on the right, with localized abdominal tenderness and rebound tenderness lateral to the umbilicus. Bowel sounds were normal, and no masses were felt. Laboratory examination