4th article

Question 1

A previously healthy, 25-year-old man was admitted to the hospital because of

Answer 1

1. abdominal pain,
2. nausea,
3. vomiting, and
4. weight loss.

Two weeks before his admission,

1. fever (temperature up to 40°C),
2. chills, and
3. weakness developed.

Question 2

To control his fever, the patient ingested ibuprofen at a dose of 400 mg four times a day for more than a week.

Subsequently,

Answer 2

abdominal discomfort and nausea developed, and he presented to the emergency department owing to worsening of epigastric pain and vomiting.

Question 3

Since his gastrointestinal symptoms had started, he had lost about 4 kg of body weight. He reported

Answer 3

no hematemesis, hematochezia, or melena. His medical history was remarkable only for a left inguinal hernioplasty 3 years earlier. He did not smoke, ingest alcohol, or use illicit drugs.

Question 4

This patient’s symptoms of

Answer 4

fever, chills, and malaise are nonspecific and may occur with viral or bacterial infection or noninfectious inflammation.

Protracted vomiting or nausea may lead to Mallory–Weiss tears at the gastroesophageal junction, causing epigastric pain and possibly upper gastrointestinal bleeding.

Pancreatitis may also explain this constellation of symptoms, although the patient reports no alcohol ingestion and has no known history of gallstones. Intestinal obstruction is another, more remote possibility. The patient’s use of ibuprofen puts him at risk for nonsteroidal antiinflammatory drug (NSAID)–induced gastritis; prepyloric edema could lead to partial gastric obstruction and vomiting. Treatment with a proton-pump inhibitor may alleviate his symptoms pending further evaluation.

Question 5

On physical examination, the patient was pale and weak but did not appear to be in distress. His blood pressure was 125/75 mm Hg in a supine position and 105/70 mm Hg while he was standing. The pulse rate was 96 beats per minute, and the temperature was 36°C. His tongue appeared dry. His tonsils were not enlarged, and there was no exudate.

There was no

Answer 5

cervical or axillary adenopathy. He had marked epigastric tenderness without rebound or abdominal rigidity. The spleen and liver were mildly enlarged. There was no rash.

Question 6

The patient’s physical examination is consistent with

Answer 6

dehydration, but there is no evidence of peritonitis, which would suggest perforation. The mild hepatic and splenic enlargement may be consistent with a viral illness, which could also explain his recent fever and its absence on admission. Alternatively, the patient’s fever may be intermittent, as in Hodgkin’s disease (Pel–Ebstein fever); the abdominal pain, weight loss, and hepatic and splenic enlargement could also be consistent with this diagnosis.