Just another bellyache?

The house officer reports that the patient was well and in good health until two weeks prior to admission, when he developed nonbilious, nonbloody emesis and decreased oral intake. For the nine days prior to his presentation, the mother noticed increasing lethargy and decreased activity in the patient. One week prior to his admission, he complained of ear pain and was seen by his primary care provider who initiated a ten-day course of amoxicillin for acute otitis media. No other symptoms were reported at the time of the diagnosis, per his mother. He continued to eat poorly, with occasional bouts of emesis. He complained of abdominal pain, periumbilical at first, but at presentation it was diffuse.

Four days ago, he was taken by his mother to an outside emergency department for evaluation. He received IV fluids and was discharged home, where he had an improved appetite and no further emesis. However, the mother reports a gradual deterioration over the past two days including decreased oral intake, decreased urine output, and diminished energy. Concerned about dehydration, she brought him to your hospital for assessment.

The resident further reports that the patient has lost six pounds in the past two weeks, attributed to his decreased appetite. He has not had fever, upper respiratory symptoms, diarrhea, or rash. His last normal bowel movement was on the morning prior to admission. The mother noticed his stool to be somewhat darker than usual. He has had decreased urine output for the 24 hours preceding his admission.

His development has been within normal limits. There were no growth charts available from the primary care doctor. He was developmentally on target. Of note, he had a lead level taken at 15 months of age, which was normal. The mother describes him as usually bright and talkative.

The floor team resident informs you that the patient has vital signs normal for his age, with the exception of mild tachycardia. His vitals are 100.2° F (37.9° C), with a respiratory rate of 32 bpm, pulse of 112 bpm, and a blood pressure of 139/90 mm Hg (patient was crying during BP). The team resident describes him as appearing tired, but in no acute distress. She reports that his physical examination is completely within normal limits, with the exception of a healed surgical scar on his left parietal scalp and dry mucus membranes. Of note, the resident describes his abdomen as soft and nontender, with normal bowel sounds and no distention or organomegaly. She informs you that emergency physicians have initiated a workup including blood work and IV fluids. She reports that the supervising physician in the emergency department was concerned about malignancy with the patient's recent weight loss and fatigue, and has ordered a lactase dehydrogenase (LDH) and uric acid panel test. The patient is currently in radiology, where he will have an abdomen acute series ordered. The series entailed two views of the abdomen, flat plate and erect. The team resident inquires about your further requests for his admission and management. You agree with her plan and tell her to call back with any new concerns, planning to see the patient in the morning on rounds.