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Vomiting and epigastric pain in an adolescent female.

CASE This 18-year-old female arrived to our emergency department (ED) with a history of having abdominal pain at her job at a fast food restaurant. She stated that the pain was midline, just below the sternum. She also said she had 2 episodes of vomiting, the last one being after arrival to the ED. The patient further related that she was on birth control pills. At the time of examination in the ED, the patient was sitting on her bed eating ice, in no distress, and awaiting further evaluation. The patient had no fever and on further questioning did not have any symptoms to suggest a urinary tract infection. Actually, she was quite comfortable. In terms of laboratory investigation, the white blood cell count was 19.9 10/mm, the hemoglobin level was 12.7 g/dL, and the hematocrit was 36.7%. The serum lipase value was 59 U/L units, and a wet vaginal preparation indicated that no trichomonas or gonorrheal infection was present. So, with all of this considered, it was believed that the patient had an acute abdominal pain, probably due to acute appendicitis. For this reason, a computed tomography study of the abdomen and pelvis with intravenous contrast was obtained. Selected images are presented in Figure 1. Do you see a problem? Remember, this is an adolescent, nearly adult, female.