GERD and Peptic Ulcer Disease USMLE Step 1 Practice Question
A 28-year-old male with a 3-year history of chronic lower back pain presents to the emergency department with sudden-onset severe epigastric pain that began 2 hours ago while he was at work. He has been taking naproxen 500 mg twice daily for the past 6 months. On examination, he appears acutely ill with severe epigastric tenderness, voluntary guarding, and rebound tenderness. Vital signs are: BP 110/68 mmHg, HR 102/min, RR 20/min, temperature 37.4°C. A stat upright chest X-ray demonstrates a 3-mm linear collection of free air beneath the right hemidiaphragm. Laboratory studies show WBC 8,200/μL, hemoglobin 14.2 g/dL, and normal liver function tests. Which of the following is the most appropriate initial management?
Answer choices
- AImmediate surgical consultation for exploratory laparotomy and repairCorrect answer
- BNasogastric tube placement, high-dose intravenous proton pump inhibitor, and serial abdominal examinations
- CUrgent esophagogastroduodenoscopy with endoscopic hemostasis
- DEmpiric broad-spectrum antibiotics and observation with repeat imaging in 6 hours
- ECT angiography of the abdomen and pelvis to evaluate for other sources of perforation
- FConservative management with intravenous H2-receptor antagonist and cessation of NSAIDs
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