Peptic ulcer case. Chief Complaint “My stomach has been hurting for the past few weeks. Over the weekend, I noticed my bowel movements were black and tarry.” HPI William Smith is a 62-year-old man who presents to the emergency department on Sunday evening complaining of intermittent burning
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Chief Complaint “My stomach has been hurting for the past few weeks. Over the weekend, I noticed my bowel movements were black and tarry.” HPI 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 agen66 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 ROS Unremarkable except for complaints noted above
VS • BP 120/62 right arm (seated), P 109, RR 18 reg, T 37.9°C; Wt 102 kg, Ht 5'9‘’
Labs • BUN 10 mg/dL • MCV 74 μm • SCr 1.1 mg/dL • FBG 154 mg/dL • Fe 49 mcg/dL • Hgb 9.2 g/dL • Ca 9.2 mg/dL • Albumin 3.9 g/dL