Here we present the case of a 20-year-old male with a known history of an artificial mechanical aortic valve replacement at ages four and twelve, on chronic warfarin therapy, who presented to our community emergency department for the evaluation of vomiting, diarrhea, generalized malaise and abdominal pain. He was seen at a local urgent care for similar symptoms earlier in the day, subsequently discharged with a diagnosis of mild gastroenteritis; however, according to the patient's sister, upon his return home he looked very unwell and she called an ambulance immediately. He stated the vomiting was nonbloody, nonbilious and without a coffee-ground appearance; the diarrhea likewise was nonbloody, nonmelenic, but mucousy. He had chills, but denies recent fevers, urinary complaints, back pain, chest pain, cough, or dyspnea. No recent illnesses, sick contacts, or travel. The patient denied any other medical or surgical history. Importantly, the patient reported no recent adjustments in his warfarin dose, admitted compliance, with last INR 2.1 two days prior to presentation.He was immediately brought to an examination room for evaluation (ESI level 1) and upon initial presentation was found to be toxic-appearing. Initial vital signs were as follows: blood pressure 88/52 mmHg, pulse rate 138 beats/minute, breathing 32 respirations/minute, a rectal temperature of 94.2 degrees Fahrenheit, and saturating 91% on ambient air. He was ashen, with sunken eyes and dry mucous membranes. Conjunctivae were pale. Cardiopulmonary exam was significant for tachypnea, tachycardia, and a systolic murmur consistent with his history of aortic valve replacement. Abdomen was soft, nondistended, diffusely tender without particular focal tenderness in any quadrant, and hypoactive bowel sounds, without peritoneal signs of guarding, rebound, or rigidity. Rectal examination revealed no gross or microscopic blood. Peripheral pulses were weak but palpable in the radial and femoral arteries. The remaining physical examination was unremarkable.Given his significant presentation and past medical history, an extensive work-up was immediately undertaken specifically focusing on inflammatory markers, bleeding studies, and imaging of the abdomen. The patient was mentating, had no signs of impending airway or breathing decompensation. Nursing staff was instructed to place two large-bore intravenous lines, with two boluses of warmed normal saline and to cover the patient with a Bair hugger. An emergent bedside ultrasound of the abdomen via RUSH protocol (rapid ultrasound for shock/hypotension) was performed by the emergency physicians, revealing a moderateto-large amount of intra-abdominal free fluid in the splenorenal, hepatorenal, and perivesicular spaces; the inferior vena cava was fully collapsed; the left ventricle was hyperdynamic; there was no evidence of pericardial effusion, abdominal aortic aneurysm or dissection. A bedside chest radiograph revealed no evidence of infi ltrates or pleural effusions, subdiaphragmatic free air, pneumothorax, or any...
