48 year-old with abdominal pain and distencion

Chief Complaint: Abdominal Pain
A 48 year-old man presented to the outpatient clinic with a 3 day history of mid epigastric pain. There was no vomiting but some nausea. He denies fever. Questionable history of some diarrhea 3-4 days prior but since then little in the way of bowel movement. On the morning when he was seen he did have a formed bowel movement. Denies weight loss, mucous in the stools or travel recently abroad. Denies peptic ulcer disease.

There is a history of beer drinking often, questionable excessive. No history of liver disease.
On exam, he appeared somewhat distressed because of abdominal distension and pain. He was afebrile. The blood pressure was normal, the pulse 95 regular and the reparations 22 per minute. The chest was clear but shallow. The heart without murmur orgallop. The abdomen was distended, minimally dystehrmic and without point tenderness. On auscultation there was hyperresonance at the epigastrium.

A flat and uprioght set of films of the abdomen are shown.

Where do we go form here in diagnositics and management?

Presented by Dr A Gordon

Recurrent bronchospasm a middle age man

46 year old male presented for follow up to the outpatient clinic because of severe flu-like, asthmatic symptoms. The patient is concerned that in recent times, during the last year, he has been battling recurrent repiratory infections. He now "remembers" that as a child he used to suffer form episodes of bronchospsm and shortness of breath with exercise. He is now susceptible to just anything in the environment. His airways are very hypersensitive. What are you thinking about in your diagnositc approach and therapy with this otherwise healthy and corpulent man?