3) Recognize the need to quickly and aggressively treat a Metformin overdose and its medical consequences. CASE INFORMATION: A 42 year-old woman with a history of diabetes, hypertension and schizoaffective disorder was found obtunded in her apartment and admitted to the MICU. She had recently been hospitalized for suicidal ideation. Empty pill bottles of a benzodiazepene, an atypical antipsychotic, a SSRI and Metformin were found. Six hours after admission, the patient developed lactic acidosisand a severe sepsis-like syndrome consistent with Metformin overdose. She subsequently became critically-ill, and had a clinical course which included severe ARDS and anuric renal failure. Support was withdrawn at the request of her family following a prolonged course of aggressive treatment. IMPLICATIONS/DISCUSSION: Metformin is commonly used in primary care and its potential for lethal side effects is well known in the setting of medical illness. This case demonstrates how Metformin also has potential for great harm in the setting of an overdose. Physicians should be aware of the risks of prescribing Metformin to diabetic patients with depression or a history of impulsive behavior. A 49 year old female with recent diagnosis of pulmonary embolism due to oral contraceptive use presented with acute onset of left sided abdominal pain associated with nausea but no vomiting, diarrhea or constipation or changes in urinary habits. Patient's medications were warfarin, ibuprofen prn, home O2 and amitryptiline. Had 25 pack year smoking history. On examination, she seemed to be in moderate distress with severe tenderness on left side of midline from epigastrium to suprapubic region, worse with any movement associated with mild fever. Vital signs were stable otherwise. Stools hemoccult negative. Lab studies revealed a wbc count of 12,700, Hb of 10.7, noted to be reduced from previous admission. Creatinine 0.7 mg/dl, lipase 94 mg/dl, PT 23.1, INR 3.73 with normal liver function tests and normal UA. Contrast enhanced CT revealed acute hematoma of left rectus sheath, 20cm Â 6cm with active bleeding. Patient's Hb further dropped so eventually transfused, coumadin stopped and surgery consulted. They suggested conservative treatment with analgesia and rest and later on, IVC filter placement. Repeat CT Scan showed stable hematoma. Patient clinically better with stable Hb. So, again started on low dose coumadin and sent home with caution not to smoke and avoid trauma as on further questioning, eventually, patient provided history of fall. IMPLICATIONS/DISCUSSION: Left sided abdominal pain and fever can be mistaken for number of causes of acute diseases of abdomen. But, due to advent of CT, an unusual diagnosis is relatively easy to make. But, since rectus sheath hematoma is one of the reported complications of anticoagulation therapy, this diagnosis should always be kept in mind. Once diagnosis is established and if this hematoma is not causing severe symptoms, the condition can be managed nonoperatively with bed rest and analgesics. Ideally, anticoagulation should be discontinued. It is rarely necessary to reverse the coagulation defect if operation is not undertaken. As in our case, patient was clinically improved so it was decided to manage her conservatively and avoid surgery. She was restarted on anticoagulation because risk of pulmonary embolism is greater than hematoma. It was made sure to counsel her about any trauma as it increases risk of hematomas in future. Patient continued to do well on further follow ups.