One Surprise after Another

A previously healthy, 22-year-old man presented to an emergency department reporting three days of intermittent abdominal pain. Although the pain was initially mild and crampy and was relieved with bismuth subsalicylate, on the day he went to the hospital the patient awoke with severe, midepigastric pain and had two episodes of diarrhea. During the preceding week, he had had a productive cough and had noticed a slight decrease in exercise tolerance. A previously healthy, 22-year-old man presented to an emergency department reporting three days of intermittent abdominal pain. On the day he went to the hospital the patient awoke with severe, midepigastric pain. 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 previously healthy 22-year-old man presented to an emergency department reporting that he had had three days of intermittent abdominal pain. Although the pain was initially mild and crampy and was relieved with bismuth subsalicylate, on the day he went to the hospital the patient awoke with severe, midepigastric pain and had two episodes of diarrhea. He reported that he had had nausea and had decreased his oral intake over the past several days. He said there had been no vomiting, dysuria, fever, chills, or ingestion of unusual or undercooked foods and no recent travel. During the preceding week, . . .