Skip to Main Content

Instructors can request access to the Casebook Instructor's Guide on AccessPharmacy. Email User Services ( for more information.


After completing this case study, the reader should be able to:

  • Identify risk factors associated with stress gastritis/ulceration and determine which critically ill patients should receive pharmacologic prophylaxis.

  • Recommend appropriate pharmacologic alternatives including agent, route of administration, and dose for the prevention of stress–induced gastritis/ulceration.

  • Identify and implement monitoring parameters for the recommended stress gastritis/ulceration prophylactic regimens.

  • Discuss the pharmacologic approaches to the management of stress ulcer–induced bleeding.



No complaint—patient is unresponsive.


Penny Robinson is a 26-year-old woman who presents to the ED with traumatic injuries following a motor vehicle accident. She was the restrained driver of a car who was hit on the driver’s side by a tractor-trailer that ran a red light. When EMS arrived in the field, the patient was unresponsive with labored breathing. She was given fentanyl 50 mcg, succinylcholine 40 mg, midazolam 5 mg, and was intubated prior to transfer to the hospital. The EMS report indicates that the intubation was very difficult. The extraction time from the vehicle to the ED was 25 minutes.

PMH (Provided by Patient’s Mother)

  • PE × 1 about 2 months ago

  • IBS-C × 10 years

  • S/P cholecystectomy about 6 months ago


Both mother and father are still alive and in “good health.”


Patient is a graduate student at a local university. She smoked cigarettes 1 ppd × 6 years until she was hospitalized for a PE and has since quit. She does not drink alcohol or use illicit drugs.


Patient is unresponsive after an MVA


  • Norethindrone 0.35 mg PO daily

  • Lubiprostone 24 mcg PO Q 12 H

  • Rivaroxaban 20 mg PO daily


  • Sulfamethoxazole/trimethoprim (shortness of breath)

  • Clindamycin (hives)

  • Cimetidine (shortness of breath and thrombocytopenia)

Physical Examination


Young, unresponsive woman; no obvious bleeding on exam


BP 108/68, P 106, RR 24, T 37.3°C; Wt 51 kg, Ht 5′11″


Warm, dry; small lacerations across forehead and chest; ecchymoses present on both legs and arms

Neck/Lymph Nodes

Supple, no palpable areas of deformity or masses


No blood visible in the nose or ears; no obvious damage to the ears, ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.