Index of Suspicion

Case 1 Presentation

A 12-year-old boy has had abdominal pain for 6 hours. His initial discomfort was epigastric and progressed rapidly to involve the entire abdomen and to radiate to the back. He vomited nonbilious material twice, which relieved the pain. He has had no diarrhea, exposure to potentially contaminated food, abdominal trauma, drug ingestion, or signs of systemic illness.

On physical examination, his rectal temperature is 38°C (100.4°F), blood pressure is 130/70 mm Hg, pulse is 96 beats/min, and respiratory rate is 24 breaths/min. The boy is in moderate pain. His throat is erythematous, but no exudate or cervical lymph nodes are detected. His lungs are clear, and cardiac sounds are normal. There is generalized abdominal tenderness, more prominent over the epigastric area, but no rebound tenderness is elicited, and no masses are palpable. Bowel sounds are diminished; rectal examination yields normal findings.

Analysis of his blood reveals hemoglobin, 170 g/L (17.0 g/dL); total white blood cell count, 25.4 10⁹/L (25.4 10³/mcL) with 82% neutrophils; platelet count, 403 10⁹/L (403,000/mcL); blood glucose, 7.44 mmol/L (134 mg/dL); normal electrolyte levels; urea nitrogen, 5 mmol/L (14 mg/dL); creatinine, 53 mcmol/L (0.6 mg/dL); calcium, 3.18 mmol/L (12.7 mg/dL); phosphorus, 1.0 mmol/L (3.0 mg/dL); alkaline phosphatase, 178 U/L; aspartate aminotransferase, 33 U/L; alanine aminotransferase, 30 U/L; bilirubin, 13.6 mcmol/L (0.8 mg/dL); amylase, 543 U/L (normal, 25 to 115 U/L); and lipase, 37 U/L (normal, 11 to 29 U/L). Urinalysis reveals normal findings, and a urine culture is sterile. Ultrasonography documents a moderately enlarged pancreas with a small amount of free fluid and small amount of ascites; the gallbladder, spleen, and kidneys appear normal.

Case 2 Presentation

A 7-year-old boy comes to the clinic because of scrotal swelling that he first noted 36 hours ago and disclosed to his mother today. He has been …