Gastrointestinal: Parents report their child is experiencing a sudden onset of intermittent, severe abdominal pain. Parents report their child has inconsolable crying and drawing up of the legs toward the abdomen. Parents report bilious vomiting that started yesterday. The child had a red, currant, jelly-like stool during the exam. The parents describe these symptoms as episodes that occur 2- 3 times daily. The symptoms started two days ago.

Temperature 97.5° F (36.4° C)

Pulse 130

Respirations 34

Pulse oximetry 95% on room air

1310: The child is crying and inconsolable. The child was difficult to examine because he was lying in the fetal position with his knees drawn to his chest. The parents are concerned that this recent vaccination of hepatitis A may be the reason. They were 2 months behind schedule, and an outbreak of hepatitis A at his daycare prompted recent vaccination.

1359: Child stopped crying and was assessed. On assessment, the child responded to verbal stimuli and moved all four extremities without delay. Skin was pale and warm to the touch. Normoactive bowel sounds in all four quadrants. No abdominal distention. No abdominal tenderness with palpation. Brachial pulse 2+. No peripheral edema.

• alkaline phosphatase 35 IU/L [30-120 IU/L]
• total bilirubin 0.5 mg/dL [0.3-1 mg/dL]
• aspartate aminotransferase 30 units/L [0–35 units/L]
• alanine aminotransferase 16 units/L [4–36 units/L]