Case 1 :

A 45-year-old male, bank vice-president comes to the emergency room complaining of fatigue and lightheadedness. Upon questioning, the patient states that his stools had become black and sticky over the past several days and were particularly malodorous. He states that his chronic epigastric pain had worsened over the past few weeks. He usually drinks two martinis during his daily business luncheons and frequently has another before dinner at night. He uses NSAIDS prn for joint aches/pains, and takes a diuretic for his hypertension. He has smoked two packs of cigarettes daily for the past ten years.

His medical history and family history are unremarkable.

Physical examination reveals an overweight, anxious man with cool, moist skin. His supine blood pressure is 118/80; pulse = 110. Upon standing, the blood pressure is 98/60; pulse = 140. He complains of dizziness upon standing. The abdominal exam reveals a 12 cm liver span in the mid-clavicular tine with a smooth, non-tender edge. The remainder of the physical examination is normal. The rectal exam reveals melena.