LAUSR

A 14-year-old female with a history of hemorrhoids is transferred from a community hospital with a 3-week history of nausea and multiple episodes of vomiting. The patient reports subjective weight loss of 21 pounds over 2 months, which she attributes to decreased oral intake secondary to loss of appetite. She reports that she underwent menarche at the age of 13 and states that her menstrual cycle has been regular with normal flow, lasting approximately 5 days. Her symptoms did not coincide with her menses, and she denies ever being sexually active. She denies dysuria and changes in urinary frequency or habits. The patient also denies recent abdominal trauma, abnormal vaginal bleeding, hematochezia, constipation, and diarrhea. At the outside emergency department (ED), the patient is hemodynamically stable. She weighs 69.45 kg with a body mass index in the 91 percentile. An acute abdominal series shows a nonobstructive bowel gas pattern, normal liver, and gallbladder demonstrating multiple tiny calculi and biliary dilatation. An abdominal ultrasound reveals small layering stones and sludge within the gallbladder but no wall thickening. The right kidney is not visualized, and the left kidney is enlarged. A pelvic ultrasound reveals a possible bicornuate uterus. A comprehensive metabolic panel and complete blood count are unremarkable. Urinalysis reveals 20 to 50 white blood cells per highpower field (HPF) and 2 to 5 red blood cells/HPF. Her urine drug screen is negative. Physical examination in the ED is notable for the absence of hemorrhoids. The patient receives 1 dose of ceftriaxone at the outside facility and is transferred to our hospital for further evaluation.