Cаrmen Ruiz, аge 34, repоrts fаtigue, cоld intоlerance, constipation, irregular menstrual cycles, increased facial hair, and difficulty becoming pregnant. Assessment reveals central adiposity. Laboratory testing shows insulin resistance, increased androgen activity, a low T4 level, and an elevated TSH level. Carmen is diagnosed with primary hypothyroidism and polyendocrine metabolic ovarian syndrome. Following fertility care, Carmen becomes pregnant. At 31 weeks’ gestation, she develops hypertension, proteinuria, a persistent headache, visual changes, and right-upper-quadrant pain. Several years later, Carmen undergoes bariatric surgery. She subsequently develops fatigue, numbness and tingling in her feet, and megaloblastic anemia. During a later illness, she has prolonged inadequate nutritional intake. Carmen also has chronic gastroesophageal reflux. She is later hospitalized with sudden epigastric pain radiating to her back, nausea, vomiting, and an elevated serum lipase level. During this admission, she develops severe intermittent flank pain and hematuria. Imaging identifies a ureteral calculus with dilation of the urinary structures above the obstruction.