2. May 17 – First presentation 14 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 foods Pain often resolved when she vomits No coffee emesis. Primarily food, sometimes bile

3. Significant Family History – 14 yr old cousin has had cholecystitis and cholecstectomy Appears to have strong open relationship with mother On Exam Appears well, fit. Appropriate weight (hockey player) No sores on hands or in mouth Abdominal exam insignificant except for slight tenderness in RUQ with Murphy’s. Differentials – gastric ulcer, cholestasis, cholelithiasis, bulimia or anorexia ….

4. Labs May 18 WBC – normal but monocytes (0.88) and basophils (0.21) slightly elevated RBC, Hbg, Hct, platelets – normal Bilirubin, AST, ALT, GGTP – normal Alk Phos – Low – (79 – normal 170-500) Lipase – Low (barely – 20, low = 22) H Pylori – neg

5. May 24 – to review labs c/o sore throat and swollen tonsils for one day. Otherwise feeling fine. Discussed bulimia N, V and abdominal pain – no change in these Sx On exam Tonsils +2, erythematous patches, no purulent discharge, no cervical lymphadenpathy. More labs ordered Abdominal U/S ordered Throat swab done

6. May 26 – office visit Throat more painful. Some difficulty swallowing. No other specific Sx. On Exam – afebrile. Tonsils +3, moderatley inflammed, few exudative crypts Swab not back Rx for Pen v 300 mg TID x 10/7. Discussed holding until swab results back May 27 – message left at home re throat swab result - negative

7. May 31 - labs repeated Urine 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)

8. June 1 – recall - saw physician Liver tender edge at right costal margin Spleen not palpable Tonsils ++ + Mono and elevated LFT’s Stop Pen V No contact sports

9. June 7 In to discuss return to school for mono Fatigued, but exams looming, needs to go back On exam – Tonsils large, no erythema or exudate. Will return to school as able, no PE F/U visit in one month - Recheck liver enzymes and to assess for fitness for hockey camp in July

10. 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.

11. June 16 Discussed 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.

12. And more story to come …… July 12 I am seeing the patient just before this presentation …..

13. So – Abd pain post eating, particularly fatty meals or large meals Symptom relief by vomiting Lays 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

14. So – my next visit Repeat labs – liver enzymes, CBC Explore menstrual history – preg test More focus on social / family context Abdominal exam paying more attention to pelvic area Another abdominal ultrasound? Pelvic ultrasound? Too invasive (includes transvaginal)? Referral to pediatrician Any other ideas? Any other differentials?