NORCET 5 Prelims - Sept 2023 (Shift-1)
Medical & Surgical Nursing
Hard
A patient comes in the ED with hematemesis and mild splenomegaly. What would be the possible cause?
Appeared in: NORCET 5 Prelims - Sept 2023 (Shift-1)
Explanation
- The combination of hematemesis (vomiting blood) and splenomegaly (enlarged spleen) is a classic presentation of portal hypertension.
- Esophageal varices are dilated submucosal veins in the esophagus that occur in patients with portal hypertension, most commonly due to liver cirrhosis.
- Portal hypertension causes blood to be shunted to the esophageal veins, leading to varices, and also causes congestive splenomegaly.
- Rupture and bleeding from these varices is a life-threatening emergency that presents as hematemesis.
Why Other Options Were Wrong
- Option A: While gastritis can cause hematemesis from inflammation of the stomach lining, it does not cause splenomegaly. The presence of both symptoms makes another diagnosis more likely.
- Option B: Pneumonia is a lung infection and is not associated with either hematemesis or splenomegaly. Patients may have hemoptysis (coughing blood), which is different from vomiting blood.
- Option D: Leukemia can cause splenomegaly and can lead to bleeding due to thrombocytopenia. However, it is a less common cause of acute, significant hematemesis compared to ruptured varices.
Related Visual
Clinical Relevance
- Nursing practice connection: Use the key finding related to Differential diagnosis of upper GI bleeding with splenomegaly to guide bedside assessment, documentation, and the next nursing action.
- Recognizing the link between hematemesis and splenomegaly is critical for nurses to anticipate a diagnosis of esophageal varices, a life-threatening emergency requiring immediate intervention.
- Nursing priorities for a patient with suspected variceal bleeding include securing IV access (two large-bore cannulas), monitoring for hypovolemic shock, and preparing for emergency endoscopy and potential balloon tamponade.
- What if? If the patient had hematemesis but no splenomegaly and a history of heavy NSAID use, the most likely cause would shift from esophageal varices to gastritis or a peptic ulcer.
How to Approach the Question
- First, identify the key signs and symptoms in the clinical scenario: hematemesis and mild splenomegaly.
- Consider the pathophysiology of each symptom. Hematemesis indicates upper GI bleeding. Splenomegaly indicates a systemic issue like portal hypertension, infection, or a hematologic disorder.
- Evaluate each option to see which one provides a unified explanation for BOTH symptoms.
- Option A (Gastritis) explains hematemesis but not splenomegaly. Option B (Pneumonia) explains neither. Option D (Leukemia) explains splenomegaly but is a less common cause of acute hematemesis.
- Recognize that Esophageal Varices, caused by portal hypertension, is the only option that directly links upper GI bleeding (from variceal rupture) with splenomegaly (from venous congestion).
- Therefore, select the option that best explains the complete clinical picture.
Concept Tested & Keywords
- Concept Tested: Differential diagnosis of upper GI bleeding with splenomegaly.
- Stem keywords: hematemesis, mild splenomegaly, ED
- Lead-in keywords: possible cause
- Clinical cues: The combination of hematemesis and splenomegaly is a key clinical pairing that points towards portal hypertension.
Question ID
Q9HRdC3v2JFJ5VspXEFIIZ
Reference Book
E6 Pathology- ROBBINS & COTRAN PATHOLOGIC BASIS OF DISEASE 10TH Ed p. 761-763
E6 Medicine Harrison 22e Part 2 p. 617-619
E6 Nelson Textbook of Pediatrics(2024) — Volume 2 p. 289-291
Practise the full NORCET 5 Prelims - Sept 2023 (Shift-1)
Attempt every question from this paper in a timed mock, then review the full solution for each one.
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