Sonu, a 15 years old girl, a regular swimmer presents with sudden onset of pain in abdomen, abdominal distension and fever of 39deg C and obliteration fo the liver dullness. Most probable diagnosis is ?
Ruptured typhoid ulcer
Primary bacterial peritonitis
Ruptured ectopic pregnancy
UTI with PID.
Ans. is 'a' ie. Ruptured typhoid ulcer The clue to this answer is presence of this clinical sign in the pt. --) Obliteration of liver dullness. Obliteration of liver dullness : Right mid-axillary line is percussed from above downwoards. The percussion note will be resonant in the upper pa of the mid-axillary line. At the upper border of the liver the resonant note in replaced by the dull note. If the liver dullness is replaced by a resonant note it indicates presence of free gas under the diaphragm as occurs in the perforation of the gastro-intestinal tract." - S.Das Manual, 4/e, p344 No other condition is able to cause obliteration of liver dullness.