William Smith is a 62-year-old man who presents to the emergency
department on Sunday evening complaining of intermittent burning
epigastric pain for more than 2 months. His pain is non-radiating and
occurs to the right of his epigastrium. This pain changes in intensity
and is worse with meals. He also has noticed intermittent belching,
being bloated, being weak when walking, and complains of nausea
after eating. Since last Friday, he has been having black, tarry bowel
movements. He does not have any history of PUD or GI bleeding and
has not experienced anorexia or vomiting.

 PMH
COPD × 10 years
Type 2 DM × 10 years
Osteoarthritis × 15 years in the right shoulder

 FH
His father died at age 55 of an acute MI and his mother died at age
66 from lung CA. He has three siblings who are alive and well.

 SH
Presently employed as an accountant. He is married and has three
daughters. He still smokes a cigar occasionally despite his COPD,
and he drinks a case of beer per week.

 Meds
Metformin 500 mg po twice daily
EC aspirin 325 mg po once daily
Ipratropium MDI 2 puffs 4 times daily
Albuterol MDI 2 puffs PRN
Ibuprofen 200 mg 2 tablets PRN shoulder pain
Maalox 1 tablespoonful PRN stomach pain

 All
Penicillin—hives

 ROS
Unremarkable except for complaints noted above
 Physical Examination

Gen
Overweight man in moderate distress

VS
BP 120/62 right arm (seated), P 109, RR 18 reg, T 37.9°C; Wt 102
kg, Ht 5'9''

Skin
Warm and dry

HEENT
PERRLA; EOMI; discs flat; no AV nicking, hemorrhages, or exudates
Chest
Bilateral rhonchi, faint wheezes

CV
S1 and S2 normal; no MRG

Abd
Normal bowel sounds and mild epigastric tenderness; liver size
normal; no splenomegaly or masses observed

Rect
Nontender; melenic stool found in rectal vault; stool heme (+)

Ext
Normal ROM except for restricted right shoulder movement
Neuro
CN II–XII intact, DTRs 2 + throughout

 Labs
Na 144 mEq/L Hgb 9.2 g/dL Ca 9.2 mg/dL
K 3.9 mEq/L Hct 26.2% Mg 2.0 mEq/L
Cl 98 mEq/L Plt 230 × 103/mm3 Phos 4.0 mg/dL
CO2 30 mEq/L WBC 8.4 × 103/mm3 Albumin 3.9 g/dL
BUN 10 mg/dL MCV 74 μm3
SCr 1.1 mg/dL Retic 0.3%
FBG 154 mg/dL Fe 49 mcg/dL

 Peripheral Blood Smear
Positive for microcytic anemia