test 2 medical diagnosis
A 72-year-old woman presents because she "threw up fresh blood" 1 hour ago. She denies any
heartburn or gastric symptoms. Her past medical history includes type 2 diabetes controlled with
diet and glyburide and naproxen for severe chronic osteoarthritis. On initial examination, she
appears anxious, but she is ambulatory and has no noticeable pallor. Family history is unremarkable.
Vital signs are as follows: BP 140/80 mm Hg without postural hypotension, HR 104 bpm, and RR 18
bpm. The rest of the physical examination shows no abnormalities.
Question
The patient is admitted and undergoes upper endoscopy. What finding is most probable? - ✔✔
correct answer Correct answer:
Gastritis
Explanation
Non-steroidal anti-inflammatory agents (NSAIDs) cause ulcer diathesis because they inhibit
prostaglandin synthesis. Virtually all NSAID users develop some degree of gastritis, and hemorrhagic
gastritis is a common cause of upper gastrointestinal bleeding in these patients. Among common
over-the-counter medications, naproxen and aspirin carry a higher risk than ibuprofen. Patients with
gastritis often experience upper abdominal pain, but many people with gastritis are asymptomatic.
Erosions and ulceration, sometimes with multiple ulcers, are also common. Endoscopic studies have
shown that 15-20% of chronic NSAID users develop ulcers, but most of these lesions are not
associated with serious complications (bleeding, perforation, etc), and screening is not indicated.
Chronic NSAID users have a 2-4% per year risk of upper gastrointestinal bleeding. It is estimated that
NSAID-associated bleeding causes 2600 deaths annually in the United States. Its incidence is rising
because of population aging, which has led to an increased number of people with chronic rheumatic
conditions.
The following factors are associated with a higher risk of bleeding:
Risk Factor Risk Increase
Age >60 5-6-fold
Anticoagulant use 10-15-fold
Glucocorticoid use 4-5-fold
Prior GI event (e.g., ulcer, bleeding) 4-5-fold
High NSAID dosage (>2x normal) 10-fold
In patients with several risk factors, the incidence of bleeding can be as high as 9% per 6 months.
, test 2 medical diagnosis
Helicobacter pylori colonization is being increasingly recognized as a risk factor for bleeding in
chronic NSAID users. Some studies showed a lower incidence of bleeding after H. pylori eradication,
which has led some investigators to propose testing and eradication in patients at high risk of
bleeding. The role of anti-H. pylori therapy in chronic NSAID use
Case
A 45-year-old man presents with a 2-day history of burning, left-sided chest pain; he denies any
trauma to the chest. On examination, you note a vesicular rash over the left T10 dermatome.
Question
What is the most likely cause of his chest pain? - ✔✔ correct answer Correct answer:
Herpes zoster
Explanation
Herpes zoster pain is usually described as sharp or burning. On examination, there is usually a
unilateral vesicular rash with a dermatomal distribution. In some cases, the pain may precede the
lesions.
Musculoskeletal chest pain, which can be unilateral or bilateral, is usually described as an aching
pain; it is aggravated by movement. On examination, tenderness may be elicited upon application of
pressure over the affected chest wall.
Spontaneous pneumothorax pain has a sudden onset; patients present within a few hours of its
onset. It is usually pleuritic in nature. On examination, the patient may be dyspneic, with decreased
breath sounds on the affected side.
Angina pain is usually described as tightness or pressure in the chest; it lasts for less than 10 minutes.
It is usually left-sided or retrosternal, and it may radiate to the jaw, neck, and shoulder. It is
precipitated by physical exertion or emotional stress and is relieved by rest and sublingual
nitroglycerin.
Pericarditis pain is usually described as a sharp, retrosternal pain that is often worse when the
patient is supine. It is relieved by sitting upright, and it is aggravated by deep inspiration and changes
A 72-year-old woman presents because she "threw up fresh blood" 1 hour ago. She denies any
heartburn or gastric symptoms. Her past medical history includes type 2 diabetes controlled with
diet and glyburide and naproxen for severe chronic osteoarthritis. On initial examination, she
appears anxious, but she is ambulatory and has no noticeable pallor. Family history is unremarkable.
Vital signs are as follows: BP 140/80 mm Hg without postural hypotension, HR 104 bpm, and RR 18
bpm. The rest of the physical examination shows no abnormalities.
Question
The patient is admitted and undergoes upper endoscopy. What finding is most probable? - ✔✔
correct answer Correct answer:
Gastritis
Explanation
Non-steroidal anti-inflammatory agents (NSAIDs) cause ulcer diathesis because they inhibit
prostaglandin synthesis. Virtually all NSAID users develop some degree of gastritis, and hemorrhagic
gastritis is a common cause of upper gastrointestinal bleeding in these patients. Among common
over-the-counter medications, naproxen and aspirin carry a higher risk than ibuprofen. Patients with
gastritis often experience upper abdominal pain, but many people with gastritis are asymptomatic.
Erosions and ulceration, sometimes with multiple ulcers, are also common. Endoscopic studies have
shown that 15-20% of chronic NSAID users develop ulcers, but most of these lesions are not
associated with serious complications (bleeding, perforation, etc), and screening is not indicated.
Chronic NSAID users have a 2-4% per year risk of upper gastrointestinal bleeding. It is estimated that
NSAID-associated bleeding causes 2600 deaths annually in the United States. Its incidence is rising
because of population aging, which has led to an increased number of people with chronic rheumatic
conditions.
The following factors are associated with a higher risk of bleeding:
Risk Factor Risk Increase
Age >60 5-6-fold
Anticoagulant use 10-15-fold
Glucocorticoid use 4-5-fold
Prior GI event (e.g., ulcer, bleeding) 4-5-fold
High NSAID dosage (>2x normal) 10-fold
In patients with several risk factors, the incidence of bleeding can be as high as 9% per 6 months.
, test 2 medical diagnosis
Helicobacter pylori colonization is being increasingly recognized as a risk factor for bleeding in
chronic NSAID users. Some studies showed a lower incidence of bleeding after H. pylori eradication,
which has led some investigators to propose testing and eradication in patients at high risk of
bleeding. The role of anti-H. pylori therapy in chronic NSAID use
Case
A 45-year-old man presents with a 2-day history of burning, left-sided chest pain; he denies any
trauma to the chest. On examination, you note a vesicular rash over the left T10 dermatome.
Question
What is the most likely cause of his chest pain? - ✔✔ correct answer Correct answer:
Herpes zoster
Explanation
Herpes zoster pain is usually described as sharp or burning. On examination, there is usually a
unilateral vesicular rash with a dermatomal distribution. In some cases, the pain may precede the
lesions.
Musculoskeletal chest pain, which can be unilateral or bilateral, is usually described as an aching
pain; it is aggravated by movement. On examination, tenderness may be elicited upon application of
pressure over the affected chest wall.
Spontaneous pneumothorax pain has a sudden onset; patients present within a few hours of its
onset. It is usually pleuritic in nature. On examination, the patient may be dyspneic, with decreased
breath sounds on the affected side.
Angina pain is usually described as tightness or pressure in the chest; it lasts for less than 10 minutes.
It is usually left-sided or retrosternal, and it may radiate to the jaw, neck, and shoulder. It is
precipitated by physical exertion or emotional stress and is relieved by rest and sublingual
nitroglycerin.
Pericarditis pain is usually described as a sharp, retrosternal pain that is often worse when the
patient is supine. It is relieved by sitting upright, and it is aggravated by deep inspiration and changes
