The approach to clinical conundrums by an expert clinician is revealed through presentation of an actual patient’s case in an approach typical of morning report. Similar to patient care, sequential pieces of information are provided to the clinician who is unfamiliar with the case. The focus is on the thought processes of both the clinical team caring for the patient and the discussant. Jennifer Reilly Lukela, MD 1 Rajesh S. Mangrulkar, MD 1 Lawrence M. Tierney, Jr., MD 2 John Del Valle, MD 1 Sanjay Saint, MD, MPH 1,3,4 1 Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan 2 Department of Medicine, University of California at San Francisco, San Francisco, California 3 Ann Arbor VA Health Services Research and De- velopment Field Program, Ann Arbor, Michigan 4 Patient Safety Enhancement Program, University of Michigan Health System, Ann Arbor, Michigan A Midlife Crisis A 47-year-old woman was brought to the emergency depart- ment by her family because of 1 week of abdominal pain. The pain had begun in the epigastrium but had spread across the abdomen. She described it as constant and 10 of 10 in intensity but could not identify aggravating or alleviating factors. She also complained of nausea and vomiting, beginning 4 days prior to presentation, occurring 2-5 times per day. She noted poor oral intake and mild diarrhea. She denied melena or hematochezia. She reported no recent fever, dysuria, chills, or night sweats; however, she reported upper respiratory symptoms 2 weeks prior to presentation. On the day of presentation, her family felt she was becoming increasingly lethargic. Epigastric pain in a middle-aged woman suggests several possible diagnoses. Conditions such as acute cholecystitis begin abruptly, whereas small bowel obstruction, appendicitis, and diverticulitis start gradually. Nausea and vomiting are common concomitants of abdominal pain and are nonspecific. The absence of fever and chills is reassuring. Of greatest concern is the mental status. Ini- tially, I think of enterohemorrhagic E. coli syndromes with asso- ciated glomerulonephritis. With a more systemic metabolic ab- normality such as this, the rapid development of the disease tends to exaggerate symptoms. The patient had a history of nephrolithiasis and underwent total abdominal hysterectomy and bilateral salpingo-oopherectomy secondary to uterine fibroids in the past. She took occasional acetaminophen, smoked two cigarettes per day, and rarely con- sumed alcohol. Temperature was 38.5°C, heart rate was 160 beats/minute, respiratory rate was 28/minute, and blood pres- sure was 92/52 mm Hg; oxygen saturation was 100% breathing 2 L of oxygen by nasal cannula. She was a moderately obese Afri- can American woman in moderate distress, lying in bed moan- ing. Mucous membranes were dry. There was no lymphadenop- athy or thyromegaly. Heart rate was regular without appreciable murmur, rub, or gallop. Lungs were clear. Abdomen was soft and nondistended, with diffuse tenderness to palpation; bowel sounds were present; there was no rebound or guarding. She had normal rectal tone with brown, guaiac-negative stool. There was no costovertebral angle tenderness. She was oriented to person, place, and time but lethargic; deep tendon reflexes were 3 bilaterally, and no focal signs were elicited. CLINICAL CONUNDRUM © 2006 Society of Hospital Medicine DOI 10.1002/jhm.84 Published online in Wiley InterScience (www.interscience.wiley.com). 200