A 16-Year-Old Girl With Severe Abdominal Pain After a Hug

Elena Zafirova, MD; Milcho Panovski, MD, PhD


October 14, 2019

Physical Examination and Workup

Upon physical examination, the patient is in obvious discomfort. Her body temperature is 99.1°F (37.3°C), she has a blood pressure of 110/70 mm Hg, and her pulse is 110 beats/min. Her skin is pale and without jaundice, but she does have a diffuse urticarial rash that is most prominent on the trunk and proximal extremities. She appears well nourished and well developed.

Her chest has symmetrical movements during respiration, and clear breath sounds are noted on auscultation. Her heart sounds are normal, with a regular rhythm and no detectable murmurs. A firm mass overlying the liver edge in the right upper quadrant is noted on palpation. The entire upper abdomen is markedly tender and rigid, particularly in the right subcostal region.

Her laboratory testing is remarkable for leukocytosis, with a white blood cell (WBC) count of 18.6 × 103/µL (18.6 × 109/L) and 40% neutrophils (0.40), 22% lymphocytes (0.22), 8% monocytes (0.08), and 21% eosinophils (0.21) (reference ranges: WBC, 4.5-11 × 103/µL; neutrophils, 40%-70%; lymphocytes, 22%-44%; monocytes, 4%-11%; eosinophils, 0%-8%). An elevated total bilirubin level of 1.98 mg/dL (33.8μmol/L) was also noted (reference range, 0.3-1.0 mg/dL). Her aspartate aminotransferase (AST) level is 101 U/L and her alanine aminotransferase (ALT) level is 104.7 U/L. Her hematocrit and platelet counts are normal.

An upright x-ray of the abdomen shows a nonspecific bowel gas pattern and no findings of pneumoperitoneum. An ultrasound is performed for a suspicion of possible gallbladder disease; it reveals a large hypoechogenic zone in the liver, with irregular margins and a small amount of free fluid around the liver. A CT scan of the abdomen is subsequently performed (Figures 1 and 2).

Figure 1.

Figure 2.


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