A 78-year-old patient being treated for knee osteoarthritis reports centralized lower thoracic pain and epigastric pain that is relieved by eating. Which step would be MOST important in screening for the cause of these new symptoms?

• A. Resist the iliopsoas muscle to screen for a psoas abscess
• B. Ask if the patient has been constipated or has had diarrhea
• C. Perform an abdominal examination to screen for an abdominal aortic aneurysm
• D. Ask if the patient is taking a high dose of nonsteroidal antiinflammatory drugs

Answer: (D)

When an older patient on NSAIDs develops new upper abdominal or epigastric pain, the most likely cause is NSAID-related peptic ulcer disease. The pain pattern described—epigastric and centralized, with relief after eating—fits a duodenal-type ulcer, which is a classic manifestation of NSAID-induced gastritis/ulceration.

Therefore, the crucial screening step is to ask about NSAID use, especially high-dose or chronic NSAID therapy. This directly identifies a reversible and addressable cause: NSAIDs suppress protective prostaglandins in the stomach, increasing ulcer risk. Establishing this exposure early guides immediate actions (adjusting medications, considering gastroprotection, and evaluating for potential GI bleeding or ulcer complications) and helps prioritize further testing.

Other options don’t line up as well with the presentation. A psoas abscess would typically present with fever, localized back or flank pain, and a positive psoas sign rather than meals-relieved epigastric pain. Questioning bowel habit changes doesn’t directly explain an upper abdominal pain pattern linked to NSAID use. Screening for an abdominal aortic aneurysm is important in certain contexts, but the symptom profile here most strongly points to NSAID-induced ulcer disease.