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This is a story of a six months old boy who was brought by his mother to an urgent care center (UCC) because of fever and vomiting. His mother reported one week of runny nose and cough. On the morning of the visit to the UCC, he had several non bilious, not bloody vomiting. At the UCC, his temperature was 102 F. He was grunting and irritable. The physician sent the boy to an emergency room (ER).

Upon arrival at the ER further history revealed that he was sleepier than usual and he has not been drinking well for two day. His urination is once a day only and he is not making any tears. There was no diarrhea and his last bowel movement was three days before. The mother commented “his belly is bothering him.”

He has a two year old sister with runny nose and cough for two weeks. He was born by cesarean section for fetal distress. His birth was was 8 pounds. Motor development was normal and his immunization is up to date.

The only problem at home is his bowel frequency which is every two to three days and at times a week goes by with out any stools.

On physical examination he appears fussy but consolable. He is grunting intermittently which is more prominent when he held on a sitting position and less on standing. His temperature was 102.2 F, heart rate of 184/minute, breathing rate of 30/minute, blood pressure of 90/40, and oxygen saturation of 99%.

The only positive findings by physical examination were reduced bowel sounds and somewhat tender (pain on pressure) at the belly. The rest of the physical findings were normal.

Answer:  Appendicitis

Reference: Contemporary Pediatrics, December 2002, page 21, “Grunting, hot and vomiting: What’s the bother in Baby’s belly?”

Leo Leonidas, MD, FAAP, Assistant Clinical Professor in Pediatrics, Tufts University School of Medicine, Boston; Attending Pediatrician, Eastern Maine Medical Center, Bangor, Maine.

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