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.

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

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.

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.

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


Unremarkable except for complaints noted above
 Physical Examination

Overweight man in moderate distress

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

Warm and dry

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

S1 and S2 normal; no MRG

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

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

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

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