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A Previously Healthy 19-Year-Old Man Comes to the Emergency Department

question 122

Multiple Choice

A previously healthy 19-year-old man comes to the emergency department (ED) due to persistent abdominal discomfort. The patient previously came to the ED 3 days ago after he fell while mountain biking. He did not lose consciousness and recalls hitting the handlebars prior to flipping and landing on his back. His trauma workup-which included CT scan of the chest, abdomen, and pelvis-was negative, and he was discharged. Since then, the patient has had persistent upper abdominal discomfort and nausea, along with an episode of nonbilious emesis. Temperature is 38.1 C (100.6 F) , blood pressure is 104/62 mm Hg, and pulse is 108/min. The lungs are clear to auscultation, and heart sounds are normal. Ecchymosis is present across the upper abdomen, which is tender to palpation with voluntary guarding. Bowel sounds are decreased. Bedside ultrasonography reveals a large amount of free fluid in the upper abdomen. Which of the following is the most likely cause of this patient's condition?

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