Case 04

9 year old male with no significant pmh p/w 1 day of periumbilical pain. Patient has also had a few episodes of vomiting with decreased appetite.  Denies fever, diarrhea, dysuria, hematuria. 

PHYSICAL: 

Vitals: T: 97 P:107 BP: 112/67 RR: 20 O2Sat: 100%

Gen: well appearing.
HEENT: Mucus membranes dry.
Cardiac, lung exam WNL.
GI/Abdomen: TTP in RLQ, Guarding RLQ. No rebound, no masses.
Extremity, skin, neuro exam are unremarkable.

LABS: 

WBC: 14.2 with L shift
HG/HCT: 12.3/36
Plt: 292
BUN: 14
Cr: 0.36
Normal electrolytes and LFTs
No lipase/amylase ordered.

1. What is your differential diagnosis?

2. What should be ordered next?

3. What does the image below depict?

4.  What are the anatomical landmarks for obtaining this image? One of them is depicted below.

5. What are the ultrasound criteria for this diagnosis?  Refer to image below.