May 17 – First presentation14 year old Caucasian female presented

accompanied by mom with c/o episodes of moderately severe central epigastric and mid abdominal pain along with nausea and vomiting post meals. Episodes becoming more frequent.

Nausea common even before meals, but no pain

Sx aggravated by large meals, greasy foodsPain often resolved when she vomitsNo coffee emesis. Primarily food, sometimes

bile

Significant Family History – 14 yr old cousin has had cholecystitis and cholecstectomy

Appears to have strong open relationship with mother

On ExamAppears well, fit. Appropriate weight (hockey

player)No sores on hands or in mouthAbdominal exam insignificant except for slight

tenderness in RUQ with Murphy’s. Differentials – gastric ulcer, cholestasis,

cholelithiasis, bulimia or anorexia ….

Labs May 18WBC – normal but monocytes (0.88) and

basophils (0.21) slightly elevatedRBC, Hbg, Hct, platelets – normalBilirubin, AST, ALT, GGTP – normalAlk Phos – Low – (79 – normal 170-500)Lipase – Low (barely – 20, low = 22)H Pylori – neg

May 24 – to review labsc/o sore throat and swollen tonsils for one

day. Otherwise feeling fine. Discussed bulimiaN, V and abdominal pain – no change in these

SxOn exam

Tonsils +2, erythematous patches, no purulent discharge, no cervical lymphadenpathy.

More labs orderedAbdominal U/S orderedThroat swab done

May 26 – office visitThroat more painful. Some difficulty

swallowing. No other specific Sx.On Exam – afebrile. Tonsils +3, moderatley

inflammed, few exudative cryptsSwab not backRx for Pen v 300 mg TID x 10/7. Discussed

holding until swab results backMay 27 – message left at home re throat

swab result - negative

May 31 - labs repeatedUrine test –positive urobilinogen

- WBC elevated – 10.5– Lymphocytes – 6.48 Monocytes – 1.81 Basophils -

0.33– Reactive lymphs, positive mono spot, – FBS, Na, K, Ca2+, Mg, po4, zinc, urea, creatinine,

prtn, tissue transglutamase ab, TSH – all NORMAL– Bilirubin low (marginally), – AST 97 (10-36), ALT 123 (10-55), GGTP 112 (0-50)

ALL HIGH– Alk Phos now Normal! – B12 > 1107 (high)

June 1 – recall - saw physicianLiver tender edge at right costal margin Spleen not palpableTonsils +++ Mono and elevated LFT’s

Stop Pen VNo contact sports

June 7In to discuss return to school for monoFatigued, but exams looming, needs to

go backOn exam –Tonsils large, no erythema or exudate. Will return to school as able, no PEF/U visit in one month - Recheck liver

enzymes and to assess for fitness for hockey camp in July

• June 11 – Ultrasound• Negative for cholelithiasis. Common bile

duct N.• Liver normal. No mass. Kidneys normal.• Minimally prominent pancreatic duct in

head of pancreas, but no focal mass.• Spleen, aorta, IVC normal• ?3.4 cm hypoechoic area in pelvis,

predominantly on L. Not well imaged. ?adnexal mass lesion? Correlate with physical exam, another U/S may be of benefit.

June 16Discussed U/S results with mom (phone call)Patient to return after school exams are

over to discuss menstrual cycle etc.June 27

Phone call from mom requesting contact info for counselor. Daughter hadn’t come home the previous night, stayed at boyfriends all night and when mom checked there she had been told that she wasn’t there. Mom very distraught by the nights events, daughter was home safe though.

And more story to come ……July 12

I am seeing the patient just before this presentation …..

So – Abd pain post eating, particularly fatty

meals or large mealsSymptom relief by vomitingLays on couch and complains of pain and

that she is going to vomit. Does not try to hide vomiting behavior.

Had positive mono with elevated liver enzymes

Now further complicated by adolescent stressors and events

So – my next visitRepeat labs – liver enzymes, CBCExplore menstrual history – preg testMore focus on social / family contextAbdominal exam paying more attention to

pelvic areaAnother abdominal ultrasound? Pelvic

ultrasound? Too invasive (includes transvaginal)?

Referral to pediatricianAny other ideas?Any other differentials?