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Home , Abdominal distension, Aerophagia, Organomegaly, Review of systems

APPENDIX arrival at the emergency department, the patient is afebrile with Vignettes normal . is soft with localized in Case 1. A 12-year-old girl presented with that she the right lower quadrant and there are no masses, , has had intermittently for 3 months. Abdominal is usually or . Normal bowel sounds are present. Normal rectal exam, worse in the morning. Th ere is no specifi c location. She is nause- including heme-negative stools. Laboratory tests revealed a white ated at times. She is able to eat and maintains a normal weight. blood count of 7.5 × 109 / l, a normal urinalysis, and a negative uri- Th e pains are severe enough to keep her out of school. Th e pain nary Gram stain. does not wake her up during the night. Th ere is no relation be- tween pain and activities, intake of food, and bowel movements. Case 4. A 3-year-old girl presents with a 3-month history of ab- Th e past ( PMHX) is unremarkable. Th ere is no dominal distention and . Her bowel movements are small history of admissions or surgeries. Th ere is no history of . and frequent, averaging nine times a day. She occasionally passes Family history : One cousin (mother ’ s family) has Crohn ’ s disease. small hard pellets of stool; however, generally the stools are de- Her parents and two older brothers are healthy. Social history : She scribed as loose and containing blood and mucous. She has been is a B student but has problems with spelling and writing. She is toilet trained for 18 months but developed a not interested in sports but loves to play chess with her father. Re- few weeks before. Th ere is no associated , , , view of systems: She has occasional , which respond well , change in activity level, or . She had had to Tylenol. She reports that she tires easily. Her is variable. a signifi cant increase in the frequency of to the point She has a normal diet. She has normal bowel movements. She has that the family had to identify the location of a bathroom at any not menstruated yet; she has no or . Physical exa- place they visited. She has received several doses of magnesium ci- mination : Her height and weight are near the 75th percentile and trate without relief of symptoms. She has otherwise been a healthy in the Puberty stage II. She is not eager to be examined and looks child who is developing appropriately. PMHX : Th ere is no his- unhappy. is normal except the abdominal tory of admissions or surgeries. Th ere is no history of allergies. . Although the abdomen is soft , she reports tenderness Birth history, development, family history, social history, and review around the umbilicus. She has a slight smile on her face when tell- of systems are all normal. Physical examination demonstrates a ing this. Th ere is no rebound tenderness and there are no masses. well-nourished and well-developed girl with a weight at the 50th Stools are heme negative. percentile and a height at the 10th percentile. She had normal vi- tal signs and did not appear pale. Her abdomen was signifi cantly Case 2. A 14-year-old girl has a history of recurrent attacks of se- distended and hyper-resonant without masses, organomegaly, or vere for over 6 months. She reports two or three ascites. revealed blood and mucus in the rec- stereotyped attacks per month. First, she experienced a sudden tal vault. Her neurological exam was normal and she had normal prickling , immediately followed by intense colicky per- deep tendon refl exes in the lower extremities. Examination of the iumbilical pain accompanied by , , and the vision back and spine was normal and no sacral dimples were seen. of multicolored lights. Th ese episodes last for seconds to several minutes and end abruptly. Th ere is no alteration of conscious- Case 5. A 32-month-old boy is referred to the clinic because of ness, automatisms, or postictal . Nausea, vomiting, or during the past 4 weeks. Th e parents report is not associated with these events. PMHX : Th ere is no that his abdomen becomes more and more distended as the day history of febrile , encephalitis, meningitis, or head progresses. During the night, he has extensive episodes of fl atu- . Th ere is no history of admissions, surgeries, or allergies. lence. On awakening, his room is foul smelling and his abdomen Family history: Her mother has migraines. Social history: Normal is fl at. He has been treated with lactulose for for the development, schooling, and social interaction with her peers. Re- past 18 months. He has been withholding stools for the past 7 view of systems : Unremarkable. Physical examination : Including months. He sits on the fl oor 12– 20 times during the day and with- vital signs is normal. holds stools. He has a soft bowel movement in his diaper every 3 days and eight small soiling episodes per day. He had not had a Case 3 . A 17-year-old boy is transferred to the emergency depart- formed stool in the past 6 months. He vomits occasionally. Th e ment with a 12-h history of right-sided abdominal pain, nausea, parents say they do not see him when he is not eat- and low-grade fever. On further questioning, the patient states ing or drinking and have not noticed belching. On further ques- that over the past 10 months he has experienced four similar tioning, they reported that he had been making unusual squeaky episodes of right-sided abdominal pain. All of these previous noises for the past few weeks. PMHX : He had normal daily bowel episodes have begun in the right upper quadrant, migrated to movements until reaching 14 months of age. At 14 months of age, the right lower quadrant, and resolved spontaneously and com- constipation was diagnosed and he has had problems with con- pletely over 48 h. During these episodes, the patient experiences stipation since then. PMHX : Th ere is no history of admissions no diarrhea, receives no therapy, and has no tests or procedures or surgeries. Birth history, development, family history, social his- performed. PMHX : Th ere is no history of admissions or surger- tory, and are all normal. Physical examination ies. Th ere is no history of allergies. Family history, social history, reveals an anxious toddler. His weight is at 50th percentile and his and review of systems : Unremarkable. Physical examination : Upon height at 75 % percentile. No skin is present. Th e abdomen is distended; nontender, hyper tympanic but soft , and bowel sounds in the Emergency Room. : Unremarkable. are active. No or is noted. Th e rectal Th ere is no history of admissions or surgeries. Th ere is no his- examination reveals no perineal erythema, a normal anus, and a tory of allergies. Family history : Father had . Mother dilated rectal ampulla fi lled with gas; no stool is present. A neuro- has allergies and an autoimmune condition that is non-classifi ed. logical examination is normal, and muscle strength and tone are Sister is 16-year-old who is healthy. Social history: She lives with appropriate for age. her mother and a sister. She is an excellent student in eighth grade. Th ere are no pets at home and no history of traveling. Reviews of Case 6 . A 10-year-old girl complains of a 3-year history of in- systems : Th ere are no other medical problems. Physical examina- termittent abdominal pain that started aft er a viral illness. Th e tion: Height is at the 5th– 10th percentiles; weight at the 25th– 50th pain is continuous and periumbilical, lasting from 5 to 10 min, percentiles. Well nourished. Abdomen is soft , nontender, and with an intensity of 7 or 8 / 10, and becoming extremely severe on nondistended. Bowel sounds are present. No hepatosplenomega- some occasions, during which she bends over. Th e pain occurs ly. Rectal exam is normal. Neurological exam is grossly normal. mostly aft e r meals. Th ere is no relation with any specifi c foods. She has tried exclusion of dairy products without resolution of the Case 8. A 17-year-old girl with 1-year history of abdominal pain symptoms. Th ere is an occasional association with nausea that is mostly localized on the right upper quadrant, but also referring to not consistent. Th ere is no history of vomiting or . She right fl ank. Pain occurs daily and lasts for a few minutes to 2 or continues to be active and is able to well. Stools have been 3 h, characterized as “ stabbing, ” occasionally 10 / 10 that she makes normal, once a day. Th ere is no relation of the pain with the bow- her double over. Th e pain interferes with her sleep and may wake el movements. Th ere does not seem to be a typical daily pattern her up at night, but mostly does not let her fall asleep easily. Dif- to her pain. She was initially placed on proton pump inhibitors fi culty to sleep occurs approximately 10 times a month. In addi- and anticholinergics with minimal improvement of the symp- tion, Jennifer is not able to practice volleyball, which she likes to toms. Lately, the patient was switched to ranitidine that seemed do. Th ere is no history of vomiting, but she relates a history of to have helped for a period of time, but over the last 2 months, the frequent nausea. Th e pain seems to be triggered on occasions by symptoms have worsened and she is experiencing more frequent fatty foods, but there is no clear pattern. Th ere is no relation with and severe episodes of abdominal pain in spite of an increase in the time of day or any stressing condition but seems to become the ranitidine dose. Th e patient expresses frustration as she not worse with physical activity. Her stools are usually normal, once able to control her pain in spite of the . PMHX and or twice a day without any blood or mucus, but she relates having birth history : Unremarkable. Th ere is no history of admissions or episodes either of constipation or diarrhea without relation with surgeries. Th ere is no history of allergies. Family history : Th ere foods every 2 weeks. Th ese episodes resolve spontaneously and do is no history of GI problems. Social history : She lives with both not seem to bother her much. Because of her nausea and lack of parents. She is an excellent student in the fourth grade. Review of well-being, she has lost 20 pounds in the last year, and she com- systems : Th ere is no history of weight loss, mouth ulcers, head- plaints of decrease in appetite. She considers herself active and she aches, , or apparent emotional problems. She is eating well has normal energy. Th e patient has been studied with computed and gaining weight. Exposures : She has two cats. No history of tomography scan, hepatobiliary iminodiacetic acid scan, abdomi- exposure to spring water or tobacco smoke. Th ere is no history of nal ultrasounds, upper GI small-bowel follow through, and en- exotic travel. Physical examination : Height and weight are at the doscopy on two occasions, and she underwent a cholecystectomy 50th percentile. Physical exam is normal with the exception of the without improvement in the symptoms. She was started on Bentyl abdominal exam that revealed mild diff use tenderness on deep without resolution without change in her symptomatology. She palpation. No . No masses. No rebound, no is currently on no medications. Past medical history : She had one guarding. Rectal exam: Normal exam. Heme-negative stools. episode of at 3 years of age, but that never recurred. She is on no seizure . Past surgical history: Cholecystectomy Case 7. A 12-year-old girl with a 5-year history of abdominal earlier this year. Allergies : She is allergic to sulfa. Family history is pain. Currently, she is having pain at least once a week, lasting for unremarkable. Social history : She lives with her parents and she 2– 5 days at a time. Location of the pain is suprapubic, left lower is an excellent student. Review of systems : Th e patient denies any quadrant, and right lower quadrant. Intensity is 4 – 8 / 10. Th e pain history of headaches, upper respiratory conditions, or any other is worse early in the morning and evening and usually does not major problem. She is in a regular diet and on no medications. wake her up at night, but frequently she has diffi culty to fall asleep Physical exam : Height is at the 50th – 75th percentile and weight because of the pain. Th ere is a history of vomiting and nausea that at the 50th percentile. She appears well. General exam is normal. have resolved lately. In addition, there are occasional episodes of Abdomen: Soft . Th ere is mild tenderness on right upper quadrant heartburn that have improved with Prilosec. Pain improves with of epigastrium. No hepatosplenomegaly. No rebound, no mass- bowel movements. Bowel movements occur once a day. Th e stools es, and no guarding. Genitalia: Deferred. Rectal exam: Normal, are normal. Th ere is no relation of the pain with stress. She has heme-negative stools. tried a diet with exclusion of dairy products for a month without improvement in the symptoms. She has been repeatedly to her Case 9 . A 4-1 / 12-year-old boy with a history of “ mild ” cerebral primary care physician for this pain but she had no consultations palsy. Approximately 6 months ago, parents noted the onset of diarrhea. He is passing anywhere from three to nine stools per ago. PMHX : unremarkable. Family history: Mother has a history day. Th ey are dark brown, grainy, and loose, but they do not soak of and panic attacks for which she is under medica- completely into the diaper. At times, his mother notes a signifi cant tion. Social history : Th e patient is in ninth grade and doing poorly. foul smell in his stools. Th ere have been no partially digested food Th ere is no history of spring water exposure or exotic traveling. particles noted in his stools and no blood or mucus. Stool ova Review of systems : she has been diagnosed with depression at the and parasite and culture were negative. He oft en complaints of time of starting middle school. Denies any other trauma besides abdominal pain during meals, he then passes several bowel move- starting school at that time, but since then she has been seen by a ments before noting that the abdominal pain goes away. Gener- psychotherapist and a psychiatrist who tried diff erent medications ally, he is described as having a poor appetite and he is noted to including Celexa, Paxil, and Prozac without an improvement in have always this kind of appetite. He has gained one pound in the the symptoms. In addition, she has been taking Zantac regularly last 1 year. Past medical history : He has no history of constipation without improvement in the symptoms. When talking in private before the onset of symptoms with passing bowel movements eve- with the patient, she brings spontaneously the fact that a friend of ryday to every other day. No history of surgeries. Birth history : Th e her died in a car accident just before she restarted with an abdom- patient was born full term by vaginal delivery. He was 7 pounds inal pain. She feels that she has good support from the family for 2 ounces. Th ere were no complications. Meconium passage was her attempt to lose weight. She denies other psychological stres- documented on the fi rst 24 h of life. Family history : Family medi- sors. Physical examination: Patient is overweight, otherwise, looks cal history is remarkable for his mother who has irritable bowel healthy. Rest of the general exam is normal. Abdomen is soft . syndrome. Rest of the family history is negative for gastrointes- Th ere is mild tenderness on the periumbilical area. No stools are tinal conditions. Social history: His social history refl ects that he palpable in the abdomen. No hepatosplenomegaly. No rebound, lives with his parents. Pets include a fi sh. Th ere is no exposure to no masses. Rectal exam is normal. Stools are heme negative. well or spring water, no exotic travel, and no tobacco smoke expo- sure. He attends pre-kindergarten. Review of systems : Poor weight Case 11. A 3-year-old boy with a history of infrequent stools since gain, poor appetite, abdominal pain, and diarrhea. No nausea or 1 year of age. At that point, the patient was passing two stools per vomiting is reported. Urine output has been normal. He has a his- day, but bowel movements became less frequent and over the last tory of mild cerebral palsy with hypotonia of the arms and legs. 3 months the patient was having stools that are hard, round, and Physical examination: He is well appearing and well nourished in small every 4 to 5 days. Th ey are occasionally covered with streaks of no distress. His height is between the 75th and 90th percentile blood. He cries when passing stools. Th e patient has a good weight for age. His weight is at the 50th percentile. General exam is nor- gain in spite of being a “ picky eater.” His diet is almost limited to mal. Abdomen: Soft , nontender, nondistended with a small mass chicken, pizza, crackers, bagels, and cheese. Past medical history : palpable in the suprapubic area. No hepatosplenomegaly is noted. As above. Birth history : He was born at 37 weeks aft er induction Bowel sounds are present in all four quadrants. Rectal exam on because of large for (LGA). Th is was an uneventful inspection reveals no perianal disease. Digital exam, good anal and postnatal course. He was discharged at 36 h. Th ere sphincter tone with a large mass of soft stool in the rectal vault, was no history of . Meconium passage was unknown, but which is Hemoccult negative. Diagnostic testing: A abdominal fl at mother believes that it was within normal. Developmental history : plate performed at the time of the offi ce visit reveals a large fecal He is developmentally appropriate. Family history: He has healthy mass in the rectal vault. parents and siblings. Social history : Unremarkable. Review of sys- tems : Th ere are no skin problems, no respiratory distress, weight Case 10 . A 14-1 / 2-year-old girl with a history of abdominal pain loss, urinary abnormalities, or neurological problems. Th e patient for which she was treated 7 years ago. At that time, the pain last- is active and is never febrile. Physical examination : Th e weight and ed for a few months and then resolved until 1 month over when length are over the 95th percentile. Head circumference is at the she started having episodes of abdominal pain again. Th e pain is 90th percentile. Th e patient looks active, alert, and in no distress. located on the periumbilical area. Pain intensity is 7/ 10. Episode Rest of the general exam is normal. Abdomen: soft , nontender, lasts for a couple of minutes but they reoccur three times a day, nondistended, bowel sounds are positive, no organomegaly. two or three times a week. Th e patient also complains of occasion- : Cries when the rectal exam is done and continues to cry al association of nausea with the pain. Th ere is no relation of the for several minutes aft erwards. Anus: normal position, no fi ssures pain with food, activity, or time of the day. Stools have been typi- or skin tags are visualized. Small amount of hard stools are pal- cally normal once a day although oft entimes she relates episodes pated, heme negative. Spine: no dimples or hairy patches. of urgency, frequency, diarrhea, and pain relieved with . She remains active and with good energy level. Th ere is no history Case 12. A 13-1/ 2-year-old boy presents with a chronic history of of weight loss despite trying to loose weight. Th e patient also com- abdominal pain for the last 5 – 7 years. Th e pain is located in the plains of headaches occurring almost every day lasting for 30 min epigastric area with radiation to the chest. It is associated with for the last 2 months. Mom thinks her abdominal pain may be nausea, has a squeezing or sharp quality, and it is more prominent related to menses and that the headaches are associated with the aft er meals. Because of the presence of symptoms, he has become fact that she eats less in school in order to lose weight. Menses more anxious and afraid of eating. He had 3 kg weight loss in the have been normal 5/ 28 and regular. Her was 2 years last 6 months. Th ere have been no reports of vomiting and there is no pain or diffi culty swallowing. He reports experiencing exacer- of the general exam is normal. Abdomen: Soft , nontender, and bation of the symptoms with intake of certain foods such as fatty nondistended. Stool is palpable to the level of the umbilicus. Rec- foods, orange juice, and tacos. He has taken Mylanta and Tums tal exam on inspection reveals small amount of perianal soiling on a regular basis, and lately he started omeprazole 20 mg twice a and a patulous anus. Digital exam reveals markedly dilated rectal day with some symptom relief but no resolution. He has a bowel vault with a large amount of soft stool that tests Hemoccult nega- movement once a day to every other day and sometimes up to two tive. Neurologically, he has a normal exam. bowel movements per day. He cannot provide further details as he does not look at his stools, but denies diarrhea. Past medical his- Case 14 . A 10-year-old boy with a history of . Bowel tory : He had no problems of gastroesophageal refl ux as an infant. movements occur approximately every 15 days. Stools are of large In the past, he has also experienced alternation between diarrhea caliber and long in spite of taking three tablets of Dulcolax at bed- and constipation, poor exercise tolerance, headaches, and anxi- time every other day. He will have smears of stool in his under- ety as well as gas and sinus problems. Family history is signifi cant wear. He occasionally complains of abdominal pain that is usually for refl ux disease in paternal grandparents. Social history : He lives mild, although in the past he had two episodes when the pain was with his parents and sister. Th ere are no pets, no exposure to well severe that prompted him to go to the emergency room. Approxi- or spring water, and limited exposure to tobacco smoke. Review mately 12 h aft er taking the medications, he passes a bowel move- of systems is signifi cant for , weight loss, and poor appetite ment that improves the pain. He was never toilet trained. Mother that he relates to the presence of abdominal pain. He is not taking denies history of withholding. He has never had blood or mucous any medication for his anxiety. He currently uses LactAid milk in his stools. His past workup has included laboratory testing and and is avoiding fried foods and spicy foods. On physical examina- X-ray. In the past he has been treated with multiple medications: tion, his weight is between the 50th and 75th percentile. Th e height sorbitol, mineral oil, MiraLax, magnesium citrate, enemas, sup- is between the 90th and 95th percentile. His vital signs are stable. positories, Dulcolax, and Senokot without success. Past medical Rest of the general exam is normal. Abdominal exam shows ac- history: He had no hospitalizations or surgical procedures. Birth tive bowel sounds, and the abdomen is soft , nondistended with history: His birth history has been uneventful. He did pass meco- epigastric tenderness with deep palpation and . No nium stool in the fi rst 24 h of life. Family history is unremarkable. masses or organomegaly is appreciated. Rectal examination shows Social history: — Lives with his parents and a younger brother. He no evidence of perianal skin tags or fi ssures. Rectal vault is normal is in the fourth grade and does fairly in school. Review of systems : and containing heme-negative stools. Th e patient underwent an He has been recently diagnosed with attention-defi cit hyperactiv- esophagogastroduodenoscopy with biopsies that were normal. ity disorder and oppositional defi ant disorder. He has been medi- cated by a psychiatrist and has recently begun working with a psy- Case 13. An 8-year-old boy diagnosed with attention-defi cit hy- chologist for behavior management. He has a good appetite. He peractivity disorder consults for a 2-year history of abdominal has history of nocturnal for which he takes desmopressin pain that has resolved, and for encopresis, and constipation. Th e once nightly. Th ey have attempted to wean this medication in the patient was initially evaluated by his primary care physician who past, with reoccurrence of night time accidents. He has no history aft er obtaining a , , and bladder X-ray recommended of nausea or vomiting. Physical exam: he is well appearing. His Miralax. He transiently did well, but symptoms reoccurred. Cur- height is between the 10th and 25th percentiles for age. His weight rently, he has large-caliber bowel movements every 2 to 3 weeks is at the 5th percentile for age. Abdomen: Soft , nontender, and that clog the toilet. Th ere is soiling two to three times per day. nondistended. A mass is palpable in the suprapubic region con- Th ere is no blood or mucus in his stools. His parents noted that sistent with hard stools. No hepatosplenomegaly is noted. Bowel he is exceptionally gassy. Past medical history : He was not consti- sounds are present in all four quadrants. Rectal exam reveals a pated as an infant or young child. No hospitalizations or surgical large amount of hard stools that are Hemoccult negative. On in- procedures have been done. Birth history : He was born full term spection of his back, no sacral dimpling or tuft s are noted. by vaginal delivery. Th ere were no complications. He passed the Neurologically exam is grossly normal. meconium stool in the fi rst 24 h of life. Family history: Two ma- ternal great aunts have a positive history of . Case 15. A 15-year-old boy with pervasive developmental disor- Social history: He lives with his parents and two older siblings. der consults for encopresis. Th ere is a history of frequent bowel Th ere is well-water exposure at the grandmother ’ s house. No ex- movements usually 2 to 13 times a day. Stools are greasy, loose, otic travel. No tobacco smoke exposure. He is in third grade and and occasionally light colored and foul smelling. Th ere is no does fairly in school. Review of systems : History of weight loss and blood or mucus. Th ere is no vomiting or abdominal distention. poor appetite felt to be associated with use of Concerta. Th ere has He also has frequent episodes of enuresis. Mother feels that epi- been no nausea or vomiting. Urinary frequency seems to increase sodes get more frequent when he is anxious. He was never been when he is more constipated. He has had no . He able to be toilet trained. Mother denies withholding behavior. Th e is currently taking Concerta and MiraLax one-half capful daily. patient underwent spine magnetic resonance imaging and genetic Physical examination: He is well appearing and well nourished in workup that were normal. Past medical history : Otherwise unre- no distress. His height is measured between the 10th and 25th markable. Th ere have been no surgeries or admissions. Birth his- percentile for age. His weight is at the 50th percentile for age. Rest tory was uneventful. Family history : Unremarkable. Social history : He attends special education, physical, and occupational therapy. seem worse at any particular time of the day or level of activity. Review of systems : As noted above. Physical examination : Height On occasions it seems to become worse aft er the ingestion of spicy and weight 50% percentile. Abdomen: Soft , nontender, and non- foods or chocolate. She has missed school for 14 days during this distended. Bowel sounds are present. No masses. Rectal exam : school year. Th e patient was originally seen by her primary care Anal wink is present. No perianal fi ssures or tags. Rectal vault is physician who recommended famotidine and then later Prevacid empty. Underwear reveals evidence of soiling. without improvement in the symptoms. At that time she had an upper endoscopy that was normal. Past medical history: She had Case 16. A 12-year-old girl presents with a 2-month history of osteophyte for which she had surgery at 8 years of age. Birth his- heartburn and vomiting. Th e patient vomits clears or food. Th ere tory, family history : Unremarkable. Social history : She lives with is no late vomiting of undigested food. Th ere is no history of her parents. Mother is a nurse. In the household also there is a blood or bile in the emesis. Vomiting occurs 8– 10 times a day brother who is in the fi ft h grade. Th ere is no well water exposure, without any relation with the food or time of the day. Th e episodes no exotic traveling, and no tobacco smoke exposure. She is cur- of vomiting happen even at night time and she sometimes wakes rently in eighth grade and is an excellent student. Review of sys- up to vomit or crying because of heartburn. During the daytime tems : She has a history of constipation for which she is receiving she swallows the vomit to avoid embarrassment in school. Th e Colace daily and she is now passing normal stools every other day vomiting started at the same time that her grandmother became without straining or blood. Her are very irregu- sick (with whom she is very close). She was seen by her prima- lar and the pain becomes worse whenever she has her periods. ry care physician who prescribed Zantac and Reglan, which she Six months ago she developed severe and continuous throbbing takes only at night time (she states that the medication makes her headache, diff use located on the top of her head associated with sleepy) with only a slight improvement. She feels weak, has a nor- photophobia. She was seen by neurologist who recommended mal appetite, and is happy with her weight. Th e mother thinks she Paxil that improved the frequency and intensity of the headaches has lost 2 or 3 pounds since the onset of the symptoms. Her stools but not the abdominal pain. Her weight has not decreased and she are hard and round like balls, every other day. Th ere is a history is above the 95th percentile. She is currently on Prevacid 30 mg of straining, but she occasionally has blood in the stools, on top q.a.m. and Paxil 40 mg q.a.m., Colace one tablet q.h.s., famotidine of the stools, or aft er wiping, as well as pain upon . 40 mg q.h.s., and Omnipen two tablets everyday for ear . Th e patient denies abdominal pain, urinary symptoms, or fever. Physical exam: Her height is at the 50th percentile and weight PMHX : Unremarkable. Family history: Her mother was diag- above the 95th percentile. She appears well. General exam is nor- nosed with cancer a few months ago. Th e brother has and mal. Abdomen: Soft and there is mild tenderness in the epigastric skin rash of unknown diagnosis. Social history : She lives with her area. No hepatosplenomegaly. Bowel sounds are present. Rectal parents and twin brother. She is in fi ft h grade with good grades. exam is normal with Hemoccult-negative stools. A pH study on Review of systems : Th ere is no history of respiratory , medications was then performed that was normal. hoarseness, headaches, food allergies, skin rash, problems, mouth ulcers, fi ssures, or urinary tract infections. She has a reg- Case 18. A 16-year-old girl presents with recurrent episodes of ular diet. Physical examination: Height is at the 50th percentile, vomiting. Th e episodes are characterized by sudden onset of weight at 25th– 50th percentile, and , rate, severe epigastric pain associated with repeated vomiting ( > 10 were within normal limits. On general physical ex- times a day), dizziness, and headache lasting for 2 days, followed amination, the patient appears healthy, in no respiratory distress, by sudden improvement. Th e characteristics of the emesis vary alert, and cooperative during the examination. Tanner stage III. from clear to streaks of blood to brown. First episode occurred Abdomen: Soft , nontender, and nondistended. Bowel sounds are 3 years ago, since then she has been seen in the emergency room present. Th ere is some evidence of stools in the suprapubic area. approximately 15 times, where she is treated with Zofran, intra- No rebound and no guarding. Rectum: there is a small fi ssure at venous fl uids, Imitrex, and Morphine for headaches. During the 5 o ’clock position. No other lesions on inspection. Sphincter tone emergency room visits, she has been noted to have elevated white is normal. Stools are hard and heme positive. Laboratory data : blood count in some occasions. Blood and urine cultures have Complete blood count with diff erential, erythrocyte sedimenta- been repeatedly normal. Between episodes, the patient has mild tion rate, total protein, albumin, urinalysis normal. abdominal pain every 5 – 7 days until the next episode, which typi- cally occur 6 –8 weeks later. Past medical history : Appendectomy Case 17. A 13-year-old girl presents with a history of abdomi- at 14 years of age. Family history : Mother and brother have a his- nal pain for the past 3 years. Symptoms started when the patient tory of migraines. Social history: She lives with parents. She is cur- had her menarche. Since then, she has been having continuous rently a junior, and she is a good student. Review of systems : Th ere abdominal pain, mostly located in the epigastric area and associ- is a history of mild constipation with passage of hard stools and ated with heartburn, nausea, and back pain, but not vomiting. She straining every 2 to 3 days with normal daily stools. Patient is cur- describes the pain as burning and severe. Th e pain interferes with rently on Senna one tablet b.i.d. with improvement in symptoms. her activity and lately it has become worse. Th e patient complaints She is also on daily Zofran that seem to improve the nausea. She of abdominal pain every night and she is not able to sleep well. has a history of asthma for which she is receiving Xopenex and in- She is waking up every night because of pain. Th e pain does not haled steroids. Physical exam : Normal exam including abdomen. Rectal exam refused. Erythrocyte sedimentation rate, erythrocyte of undigested formula aft er most of the feeds for the last month. sedimentation rate, function tests, amylase, lipase, albumin, He is exclusively breastfed and gaining weight appropriately. He is urine analysis: all normal. Porphyria and Familial Mediterranean described as a pleasant baby and seems to enjoy feeding. PMHX : Fever workup negative. Esophagogastroduodenoscopy: Normal. Unremarkable. Birth history : Born full term. Uneventful preg- Abdominal X-ray: Moderate amount of stools throughout colon. nancy, delivery, and immediate postnatal course. Family and so- Abdominal ultrasound : normal. Sitz markers studies : Mildly de- cial history : Unremarkable. Review of systems: Accomplishing the layed transit. appropriate milestones for his age. Yellowish stools twice a day. Th ere is no blood in the bowel movements. No history of seizures, Case 19. A 4-week-old baby girl with a history of straining. Patient respiratory distress, or skin rash. Physical exam : Normal including was born at 37 weeks by normal vaginal delivery. Meconium pas- a normal rectal examination. Stools are heme negative. sage occurred at 24 h. During her fi rst week she was passing hard stools approximately once or twice a day. Since then the stools Options for answers have been soft and normal. Th e mother notes her to strain, cry, and (a) Infant regurgitation turn red before each bowel movement. Aft er passing stools, she (b) Infant rumination syndrome becomes quiet and goes back to her usual self. She is described as a (c) Cyclic vomiting syndrome pleasant baby. Past medical history : Th ere is no history of surgeries, (d) Dyspepsia hospitalizations, spitting up, , or gagging during or aft er (e) (f) Functional abdominal pain the feeds. Birth history, family history, social review of systems : (g) Abdominal migraine Unremarkable. Th e patient is breastfed and gaining weight sat- (h) isfactory. She is accomplishing the appropriate developmental (i) Functional diarrhea milestones. She is on no meds. Physical exam : Normal including a (j) Infant dyschezia normal rectal examination. (k) Functional constipation (l) Functional fecal retention (m) Functional nonretentive fecal soiling Case 20. A 2-month-old baby presents for evaluation of regurgita- (n) None of the above tion. Th e mother reports a history of regurgitation of small amount