A 55-Year-Old Man With Nausea and Vomiting

Mehtap Cakir, MD

Disclosures

July 30, 2015

Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case you would like to suggest for a future Case Challenge, please contact us.

Background

A 55-year-old man presents to the emergency department (ED) with a 2-day history of nausea and vomiting. He has been seen a few times in the gastroenterology clinic during the past 6 months for similar symptoms. Multivitamins, antacids, and proton-pump inhibitors had been prescribed but failed to control his symptoms. He has no history of trauma, weight loss, fever, dyspnea, abdominal pain, hematemesis, diarrhea, constipation, or peripheral edema.

Six years ago, he was diagnosed with type 2 diabetes and was prescribed an oral agent and a long-acting insulin. Although he was nonadherent to his recommended diet, he used his medications as prescribed. Four years ago, the patient began experiencing hypoglycemic episodes even though his daily activity and diet had not changed and his weight had remained stable. From that point on, he gradually tapered his insulin use and eventually stopped both insulin and his oral medication. Following that, occasional fingerstick glucose measurements were reportedly normal. He does not smoke tobacco, drink alcohol, or use illicit drugs.

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