FINAL EXAM HUMAN CASE STUDY ON
ALCOHOLISM / QUESTIONS WITH VERIFIED
ANSWERS 2024/ GRADED A+
History: Vincent Miller, a 62-year-old accountant, has had a "drinking problem" throughout most of his
adult life. He drinks about a half-case of beer each day. He has lost several jobs over the years for
drinking at the workplace or showing up for work drunk. He lost his driver's license for drunk-driving,
and his drinking has placed a considerable strain on his marriage. He has tried several self-help programs
as well as Alcoholics Anonymous, all with little success. He has been hospitalized on several occasions
over the years. Vincent has a severe tremor in his hands (probably a result of excessive alcohol intake),
which makes it very difficult for him to use a spoon, fork, and knife to eat. It's your first day on the job as
an occupational therapist, and you are consulted by his physician to see if there is any way to help
Vincent use eating utensils. Not knowing anything about him, you open up his past medical r - ANSWER
Continue to questions
2. Based upon your knowledge of the vomiting reflex, why might severe vomiting tear the mucosa? -
ANSWER 2. The following events occur as part of the vomiting reflex:
A. The individual inhales deeply and holds the diaphragm in the flattened and contracted position. In this
position, the diaphragm pushes against the stomach and raises intra-abdominal pressure.
B. The glottis closes to prevent vomitus from entering the respiratory tract.
C. The abdominal wall muscles contract (i.e. the "bearing down" or Valsalva maneuver), further
increasing intra-abdominal pressure and therefore increasing external pressure on the stomach.
D. The lower esophageal sphincter (also called the cardiac sphincter) relaxes to allow the stomach
contents to enter the esophagus and be propelled to the mouth.
E. The soft palate elevates to close off the opening into the nasal cavity.
Thus, the act of vomiting greatly increases the intra-luminal pressure in the stomach and esophagus.
This, coupled with the fact that the vomitus is very acidic, causes irritation of the lower esophageal
lining. In instances of severe, repeated bouts of vomiting, the esophageal mucosa may actually tear. This
phenomenon is called a Mallory-Weiss tear.
First Hospitalization: You note that Vincent was hospitalized at age 32 with a complaint of vomiting up
blood after a drinking binge that lasted seven days and was marked by excessive and repeated vomiting
episodes. The vomitus was bright red. The hospital chart lists a diagnosis of "Upper GI bleed" due to a
, Mallory-Weiss tear. You look up "Mallory-Weiss tear" in an internal medicine textbook and see that it is
defined as "a longitudinal tear in the mucosa at the gastroesophageal junction -- i.e. in the area of the
lower esophageal sphincter -- caused by repeated vomiting."
1. Why was the blood bright red, rather than the color of "coffee grounds"? - ANSWER 1. The bright red
color of the vomitus indicates that the blood either didn't enter the acidic environment of the stomach,
or didn't spend much time in the stomach. Blood that remains in the stomach for longer periods
becomes dark and hardens into pieces that resemble coffee grounds, hence the term "coffee ground
emesis."
Second Hospitalization: At age 36, Vincent was hospitalized again, this time with complaints of
abdominal pain in the upper epigastric region (i.e. just below the xiphoid process of the sternum) and
"coffee-grounds" emesis. He also complained of "heartburn" (a burning sensation in the area of the
sternum) which was partially relieved with antacids. A diagnosis of "upper GI bleed due to gastritis and
reflux esophagitis" is noted in the chart.
1. What is causing the pain in the upper epigastric region ? What barrier(s) normally protect the stomach
lining from its own acid? - ANSWER 1. The pain in Vincent's upper epigastric region is most likely referred
pain due to his gastritis (i.e. inflammation of the stomach lining). The stomach lining is normally
protected from the corrosive effects of its own acidic secretions in the following ways:
A. There are tight junctions between adjacent epithelial lining cells, making it difficult for secreted H+
ions to be reabsorbed back through the stomach lining.
B. The gastric glands secrete a thick coating of HCO3- - rich mucus onto the lining.
C. Gastric epithelial cells damaged by the gastric acid are quickly replaced by underlying cells.
However, excessive alcohol ingestion can break down this mucosal barrier, thus increasing its
permeability to H+ ions. The gastric acid seeping into the stomach wall can cause irritation,
inflammation, bleeding, and sometimes ulceration of the gastric lining - - the latter phenomenon being
called a peptic ulcer, because of the ability of the stomach digestive enzyme pepsin to digest the wall
itself. The presence of "coffee-ground" emesis suggests that Vincent's stomach lining is slowly bleeding,
either as a result of the gastritis or peptic ulcer or both.
2. What is reflux esophagitis? - ANSWER 2. Reflux esophagitis is inflammation of the lower esophageal
lining due to the excessive reflux of corrosive gastric acid into the duodenum. Esophageal reflux causes
referred pain in the sub-sternal region - - the same location where referred pain from ischemic heart
disease (i.e. angina pectoris) is felt, hence the term "heartburn." Causes of reflux esophagitis include
excessive relaxation (or "incompetence") of the lower esophageal sphincter, impaired esophageal
ALCOHOLISM / QUESTIONS WITH VERIFIED
ANSWERS 2024/ GRADED A+
History: Vincent Miller, a 62-year-old accountant, has had a "drinking problem" throughout most of his
adult life. He drinks about a half-case of beer each day. He has lost several jobs over the years for
drinking at the workplace or showing up for work drunk. He lost his driver's license for drunk-driving,
and his drinking has placed a considerable strain on his marriage. He has tried several self-help programs
as well as Alcoholics Anonymous, all with little success. He has been hospitalized on several occasions
over the years. Vincent has a severe tremor in his hands (probably a result of excessive alcohol intake),
which makes it very difficult for him to use a spoon, fork, and knife to eat. It's your first day on the job as
an occupational therapist, and you are consulted by his physician to see if there is any way to help
Vincent use eating utensils. Not knowing anything about him, you open up his past medical r - ANSWER
Continue to questions
2. Based upon your knowledge of the vomiting reflex, why might severe vomiting tear the mucosa? -
ANSWER 2. The following events occur as part of the vomiting reflex:
A. The individual inhales deeply and holds the diaphragm in the flattened and contracted position. In this
position, the diaphragm pushes against the stomach and raises intra-abdominal pressure.
B. The glottis closes to prevent vomitus from entering the respiratory tract.
C. The abdominal wall muscles contract (i.e. the "bearing down" or Valsalva maneuver), further
increasing intra-abdominal pressure and therefore increasing external pressure on the stomach.
D. The lower esophageal sphincter (also called the cardiac sphincter) relaxes to allow the stomach
contents to enter the esophagus and be propelled to the mouth.
E. The soft palate elevates to close off the opening into the nasal cavity.
Thus, the act of vomiting greatly increases the intra-luminal pressure in the stomach and esophagus.
This, coupled with the fact that the vomitus is very acidic, causes irritation of the lower esophageal
lining. In instances of severe, repeated bouts of vomiting, the esophageal mucosa may actually tear. This
phenomenon is called a Mallory-Weiss tear.
First Hospitalization: You note that Vincent was hospitalized at age 32 with a complaint of vomiting up
blood after a drinking binge that lasted seven days and was marked by excessive and repeated vomiting
episodes. The vomitus was bright red. The hospital chart lists a diagnosis of "Upper GI bleed" due to a
, Mallory-Weiss tear. You look up "Mallory-Weiss tear" in an internal medicine textbook and see that it is
defined as "a longitudinal tear in the mucosa at the gastroesophageal junction -- i.e. in the area of the
lower esophageal sphincter -- caused by repeated vomiting."
1. Why was the blood bright red, rather than the color of "coffee grounds"? - ANSWER 1. The bright red
color of the vomitus indicates that the blood either didn't enter the acidic environment of the stomach,
or didn't spend much time in the stomach. Blood that remains in the stomach for longer periods
becomes dark and hardens into pieces that resemble coffee grounds, hence the term "coffee ground
emesis."
Second Hospitalization: At age 36, Vincent was hospitalized again, this time with complaints of
abdominal pain in the upper epigastric region (i.e. just below the xiphoid process of the sternum) and
"coffee-grounds" emesis. He also complained of "heartburn" (a burning sensation in the area of the
sternum) which was partially relieved with antacids. A diagnosis of "upper GI bleed due to gastritis and
reflux esophagitis" is noted in the chart.
1. What is causing the pain in the upper epigastric region ? What barrier(s) normally protect the stomach
lining from its own acid? - ANSWER 1. The pain in Vincent's upper epigastric region is most likely referred
pain due to his gastritis (i.e. inflammation of the stomach lining). The stomach lining is normally
protected from the corrosive effects of its own acidic secretions in the following ways:
A. There are tight junctions between adjacent epithelial lining cells, making it difficult for secreted H+
ions to be reabsorbed back through the stomach lining.
B. The gastric glands secrete a thick coating of HCO3- - rich mucus onto the lining.
C. Gastric epithelial cells damaged by the gastric acid are quickly replaced by underlying cells.
However, excessive alcohol ingestion can break down this mucosal barrier, thus increasing its
permeability to H+ ions. The gastric acid seeping into the stomach wall can cause irritation,
inflammation, bleeding, and sometimes ulceration of the gastric lining - - the latter phenomenon being
called a peptic ulcer, because of the ability of the stomach digestive enzyme pepsin to digest the wall
itself. The presence of "coffee-ground" emesis suggests that Vincent's stomach lining is slowly bleeding,
either as a result of the gastritis or peptic ulcer or both.
2. What is reflux esophagitis? - ANSWER 2. Reflux esophagitis is inflammation of the lower esophageal
lining due to the excessive reflux of corrosive gastric acid into the duodenum. Esophageal reflux causes
referred pain in the sub-sternal region - - the same location where referred pain from ischemic heart
disease (i.e. angina pectoris) is felt, hence the term "heartburn." Causes of reflux esophagitis include
excessive relaxation (or "incompetence") of the lower esophageal sphincter, impaired esophageal
