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NBME 23 Answers

nbme23/Block 2/Question#18

A 48-year-old man comes to the physician because of ...

Perforated peptic ulcer

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The key is the free air in the abdominal cavity. Ulcers, especially duodenal ulcers, can perforate into the abdominal cavity. This can cause a pneumoperitoneum (free air under the diaphragm). Not a listed symptom in this question, but this can also cause referred pain to the shoulder by irritating the phrenic nerve. FA 2019 pg 374

et-tu-bromocriptine  To add on to this, anterior* duodenal ulcers tend to perforate (makes sense because closest to the abdominal cavity) whereas posterior duodenal ulcers tend to bleed (due to proximity to the gastroduodenal artery). +5  
smc213  Acute pancreatitis can also occur with a posterior duodenal ulcer rupture. Source: Pathoma +3