Springing a Leak

A 52-year-old man presented to the emergency department with general weakness and swelling in his legs. Symmetric swelling had begun 4 weeks earlier and had progressed to the point that it was difficult for him to wear shoes. Foreword In this Journal feature, information about a real patient is presented in stages (boldface type) to an expert clinician, who responds to the information, sharing his or her reasoning with the reader (regular type). The authors’ commentary follows. Stage A 52-year-old man presented to the emergency department with swelling in his legs and general weakness. Symmetric leg swelling had begun 4 weeks earlier. Two weeks before presentation, when it became difficult for him to wear shoes because of the swelling, he had presented to another emergency department, where he was found to have hyponatremia and a thyrotropin level of 89 mIU per liter. He had been taking levothyroxine at a dose of 150 μg daily, and the dose was increased to 175 μg daily. Furosemide was prescribed for swelling, with moderate benefit. Symmetric, progressive weakness and intermittent muscle . . .