• Sudden onset of severe intense, steady epigasric    pain with radiation to sides, back, or right    shoulder •  Past h/o burning, gnawing pain worse with    empty stomach •  Physical findings    - epigastric tenderness    - rebound tenderness    - abdominal muscle rigidity •  Diagnostic studies    - upright or lateral decubitis X-ray shows       air under the diaphragm or peritoneal       cavity REFER - SURGICAL EMERGENCY