A 45-year-old obese woman presents with sudden onset of epigastric pain and left shoulder discomfort two hours ago. She has anorexia but no nausea or vomiting; pain is unchanged by oral intake. Vital signs show tachycardia; abdominal exam reveals rebound tenderness that is poorly localized. What is the most appropriate management?

• A. Transfer to ED
• B. Begin oral antacids
• C. Schedule outpatient follow-up
• D. Prescribe proton pump inhibitor therapy only

Answer: (A)

Sudden, severe epigastric pain with signs of peritoneal irritation and tachycardia points to an acute abdomen that could be a life-threatening intra-abdominal process. The left shoulder discomfort suggests diaphragmatic irritation from free intraperitoneal air or another intra-abdominal pathology. Because these findings indicate potential perforation, peritonitis, or another emergent condition, immediate evaluation in the emergency department is essential for stabilization, diagnostic workup (labs and imaging), and timely management. Starting oral antacids or PPI therapy, or scheduling outpatient follow-up, would not address a possibly perforated viscus or other urgent cause and could delay necessary care. In the ED, the patient would be kept NPO, receive IV access and fluids, be assessed with imaging (such as upright chest/abdomen X-ray or CT) and labs, and receive appropriate management based on the findings.