MEDizzy - A 41-year-old male presents to your office with a complaint

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Medicine test

A 41-year-old male presents to your office with a complaint of epigastric pain for the past several months. He takes over-the-counter antacids, but symptoms have been worse over the past month. He denies any weight loss, vomiting, hematemesis, or melena. The discomfort is worse after eating. Medical history is noncontributory. He takes no other medications. He smokes half a pack of cigarettes a day and drinks alcohol socially about once per week. Physical examination is unremarkable except for mild epigastric tenderness. What is the appropriate next step in managing this patient?

ExplanationEmpiric 1-month trial with proton pump inhibitor (PPI). The patient in this question is presenting with dyspepsia (characterized by epigastric pain and early satiety). Dyspepsia is a common presentation, and only a minority of patients are diagnosed with an underlying etiology contributing to the dyspepsia. The most common etiologies of dyspepsia are GERD, NSAIDs, peptic ulcer disease (PUD), and malignancy. (D) Importantly, if a patient presents with any “alarm symptoms” such as unexplained weight loss, persistent vomiting, blood loss, dysphagia, or family history of gastrointestinal cancer, then he/she should undergo an upper GI endoscopy to evaluate for malignancy. In patients without the “alarm symptoms,” current recommendations are to test for Helicobacter pylori in regions where there is a high prevalence of the bacteria and begin treatment with a PPI. In regions where there is a low prevalence of H. pylori, some physicians will treat empirically with a PPI. The most important thing to note here is that patients who fail either of these treatment options after 4 to 8 weeks should undergo endoscopy. (A) Antacids have not alleviated this patient’s symptoms and therefore are not the correct answer here. (B) Barium swallow evaluation is not helpful in diagnosing the etiology of dyspepsia. (E) This patient is symptomatic and clearly not responding to over-the-counter antacids. Observation is inappropriate