Too Much of a Good Thing

A 54-year-old man presented to the emergency department with a 1-month history of edema in the lower legs and a 1-week history of upper abdominal pain. He also reported intermittent nausea, early satiety, and diarrhea but did not have fevers, chills, or vomiting. 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 54-year-old man presented to the emergency department with a 1-month history of edema in the lower legs and a 1-week history of abdominal pain. The abdominal pain was dull, was bandlike across the upper abdomen, and worsened with eating. In the days preceding presentation, he had intermittent nausea, early satiety, and diarrhea, but he reported no fevers, chills, or vomiting. Response The description of the upper abdominal pain as dull and bandlike suggests that the pain arises from an internal organ and its immediate peritoneal lining. Epigastric pain suggests gastroduodenal or pancreatic disease, and right subcostal pain suggests . . .