On physical examination he appears tired and pale. He is not icteric and there are no skin lesions or mouth ulcers. There is no clubbing or lymphadenopathy. Examinations of the chest and heart are normal. His abdomen is mildly distended and tympanic, but he has no abdominal tenderness nor evidence of masses or organomegaly.
Rectal exam reveals pale soft stool that is negative for occult blood.
The remainder of the examination, including the neurologic and musculoskeletal exam, is unremarkable. A Schilling's test showed malabsorption of vitamine B12, even with intrinsic factor administration. An esophagogastroduodenoscopy was unremarkable. A small bowel follow-through was performed to assess the remainder of the small bowel. This biopsy, obtained at endoscopy, reveals normal crypt-villous architecture, no increase in inflammatory cells, and normal enterocytes.