The Elusive Stomachache

Jo Ann Serota, MSN, RN, CPNP

Disclosures

J Pediatr Health Care. 2006;20(3):206-207,221-222. 

In This Article

Case Presentation

The last patient of the day presented with the elusive complaint of abdominal pain of several months' duration. This complaint has so many differentials that the pediatric nurse practitioner (PNP) must play detective to determine where to concentrate his or her efforts to obtain a diagnosis.

The patient, accompanied by her mother, was a 10-year-old White girl in the fourth grade. Her chief complaint was feeling "crabby" and having mood swings, an occasional headache, a 5-lb weight loss over several months, and abdominal pain with the feeling of being bloated after eating. According to the patient, the problem had been present for a "long, long time." She denied any vomiting, diarrhea, dysuria, night sweats, or fever. The abdominal pain was located in the upper quadrants of the abdomen. The family has not traveled out of the United States. The patient has been doing well in school; she likes her teacher and has lots of friends. Her social calendar is always full, and she takes dance and piano lessons. However, her home has been in a bit of turmoil for more than a year. Her two older brothers have chronic illnesses; the eldest has bipolar disease, and the middle brother has Tourette's syndrome. Issues with both brothers have occurred recently, upsetting the entire household. The father is trying to help out at home, but according to the mother, he just does not understand the "big picture."

"Bingo!" I thought. The abdominal pain was due to stress. Unfortunately, the situation was not so simple. Further investigation revealed a strong family history of ulcerative colitis, chronic abdominal pain, irritable bowel syndrome, and colon cancer. The patient has a few environmental allergies that do not seem to be of any consequence. The most concerning symptoms according to the patient's mother were her emotional ups and downs, loss of appetite, and chronic complaint of stomachache after eating. Her newest symptom is now refusing to eat because the abdominal discomfort is worsening.

A review of the patient's chart reveals that she had been growing appropriately along her growth curves (75% for height and 50% for weight) for the past several years. Today's measurements indicated a drop in the percentile for height to the 50th percentile and weight to the 25th percentile since her physical 10 months ago.

The abdominal pain was dull and generalized over the upper gastric area. It occurred about 20 to 30 minutes after she consumed a meal and lasted for about an hour. This abdominal discomfort is constant throughout the week, including weekends.

On physical examination, the patient was a well-developed, thin, pale 10-year-old child whose physical examination was completely normal except for boggy turbinates and slight nasal congestion. Her abdomen was soft with no organomegly, and bowel sounds were normal. She denies anyone inappropriately touching her. Her pubertal development was at Tanner Stage II.

Further investigation of the abdominal pain is necessary because there was a change in the growth curve and the child is now complaining that the discomfort is worsening.

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