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(Pediatrics in Review. 2009;30:107-113.)
© 2009 American Academy of Pediatrics

Index of Suspicion

Abbreviations: ALT: alanine aminotransferase • AST: aspartate aminotransferase • BUN: blood urea nitrogen • CBC: complete blood count • CNS: central nervous system • CSF: cerebrospinal fluid • CT: computed tomography • ECG: electrocardiography • ED: emergency department • EEG: electroencephalography • ESR: erythrocyte sedimentation rate • GI: gastrointestinal • GU: genitourinary • Hct: hematocrit • Hgb: hemoglobin • MRI: magnetic resonance imaging • WBC: white blood cell

The first 300 words of the full text of this article appear below.

	Case 1 Presentation

 
A 9-year-old boy presents to the ED with a 1-day history of increased work of breathing and cough. Over the past few days, he also has experienced increasing lethargy and fatigue. His past history is significant for situs inversus and asplenia. He has had multiple prior admissions for pneumonia and had a gastric volvulus at age 3 years, which was treated with an esophagojejunal anastomosis. He had been fed by a jejunal tube, but this was removed. The patient subsequently was lost to follow-up until recently. Current medications include fluticasone 125 mcg, 1 puff twice daily via spacer, and amoxicillin 125 mg by mouth daily; his compliance is questionable.

The physical examination reveals a pale child who does not appear toxic. His temperature is 98.6°F (37°C), heart rate is 110 beats/min, respiratory rate is 32 breaths/min, blood pressure is 104/54 mm Hg, and oxygen saturation is 92% on 6 L of oxygen/min. His height and weight are at the 40th and 25th percentiles, respectively. He has diffuse wheezing and crackles in the left base. The rest of the examination findings are unremarkable.

A chest radiograph demonstrates a left lower lobe infiltrate. Blood cultures are ordered and broad-spectrum antibiotics begun. A complete blood count demonstrates a Hgb of 5.8 g/dL (58 g/L), mean corpuscular volume (MCV) of 133.8 fL, mean corpuscular hemoglobin concentration (MCH) of 45.4 pg, WBC count of 3.16x10³/mcL (3.16x10⁹/L) (1.55x10³/mcL neutrophils, 1.51x10³/mcL lymphocytes, 0.1 x10³/mcL basophils), and platelets of 70x10³/mcL (70x10⁹/L). The peripheral smear shows Howell-Jolly bodies, multilobulated neutrophils, large platelets, macro-ovalocytes, and nucleated red blood cells. Values for serum electrolytes, alkaline phosphatase, AST, and ALT are normal. The lactate dehydrogenase concentration is 1,670 U/L, and the bilirubin . . . [Full Text of this Article]

Susanna Martin, MDCM, FRCP(C)
Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada

Kellie Waters, MD
Stollery Children's Hospital, Edmonton, Alberta, Canada

Miriam K. Perez, MD
West Virginia University School of Medicine, Morgantown, W.V

Bradey T. Kleman, MD
AP&S Pediatrics, Terre Haute, Ind

Linda S. Nield, MD
West Virginia University School of Medicine, Morgantown, W.V

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