Case 5: Right Upper Quadrant Abdominal Pain in an Otherwise Healthy 8-year-old Girl.

Abstract

1. Justin Moher, MD* 2. Cherilyn Cecchini, MD* 3. Priti Bhansali, MD* 1. *Pediatrics, Children's National Health System, Washington, DC A previously healthy 8-year-old girl presents to the emergency department with an 8-day history of intermittent high fevers, vomiting, and right upper quadrant (RUQ) abdominal pain. She was seen on day 2 of illness, diagnosed as having presumptive urinary tract infection due to pyuria, and was prescribed a course of trimethoprim-sulfamethoxazole. After 3 days of continued fevers (102.2°F–104.9°F [39.0°C–40.5°C]) and intermittent RUQ pain, the antibiotic drug course was switched to cefdinir. Her clinical course worsened, with ongoing fever, RUQ pain, vomiting, and development of dehydration, prompting presentation to the emergency department. Her travel history and animal exposure history are unremarkable. On presentation, her vital signs are significant for a heart rate of 142 beats/min and a temperature of 103.5°F (39.7°C). Her blood pressure and respiratory rate are within the reference ranges for her age. On physical examination, she is noted to have dry mucous membranes and adequate capillary refill. Her abdomen is soft, with normal bowel sounds and mild tenderness to palpation mostly in the RUQ. She does not have any rebound or guarding and has no tenderness over the McBurney point. Murphy, Rovsing, obturator, and psoas signs are all negative. Rectal examination is deferred. Findings from the remainder of the physical examination are normal. Initial laboratory test results are as follows: white blood cell count, 30,660/μL (30.6×109/L), with 79% neutrophils, 8% lymphocytes, 12% monocytes, and 1% basophils; hemoglobin level, 10 g/dL (100 g/L), with a mean corpuscular volume of …