Gastro Case Challenge: Pain, Vomiting in a 48-Year-Old on Levothyroxine, Metformin

Bashar Sharma, MD; John W. Birk, MD


September 23, 2022

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 that you would like to suggest for a future Case Challenge, please contact us.


A 48-year-old man presents to the emergency department with epigastric pain, nausea, nonbloody vomiting, and anorexia. He describes the pain as constant, with a sharp, stabbing nature. Lying in a fetal position alleviates the pain. He has no fever, chest pain, dyspnea, or recent weight loss. The pain started suddenly 2 days ago while he was at work. It progressively worsened, and he was unable to keep down oral intake. He had similar symptoms 2 months earlier; however, they were mild and resolved spontaneously.

The patient has a medical history of poorly controlled type 2 diabetes, obesity class 2 (body mass index, 35-40), hypertension, hypothyroidism, and obstructive sleep apnea treated with continuous positive airway pressure. He has not had any surgeries in the past.

His family history is significant for coronary artery disease in his father, diabetes in his mother, and alcoholic cirrhosis and chronic pancreatitis in a maternal uncle. He has no family history of gastrointestinal cancers or inflammatory bowel disease. He does not smoke cigarettes, and he drinks 1-2 glasses of wine on the weekend. He reports no illicit drug use.

He takes amlodipine (5 mg daily), levothyroxine (100  µg daily), and metformin (500 mg twice daily). He denies any new medications or changes to his current ones. He works as a paralegal and has not had any recent falls or trauma.


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