Fever, Pain, and Failure to Thrive in a 9-Year-Old Boy

Arun Phophalia, MBBS, MS; Madhu Phophalia, MD, MBBS, MS

Disclosures

December 16, 2015

Physical Examination and Workup

The child is well-nourished but appears small for his age. He is friendly and cooperative. His blood pressure is 94/68 mm Hg, pulse is 80 beats/min with a regular rhythm, oral temperature is 98.8°F (37.1°C), and respiration rate is 16 breaths/min. The patient's conjunctiva is pale, the sclera is muddy, the neck veins are not distended, and no pedal edema is noted.

Although the abdomen is slightly distended, no organs or lumps are palpable, and the bowel sounds are normal. Slight tenderness is noted in the left lumbar region on deep palpation, and the rest of the abdomen is nontender. The review of his other systems is normal. No free fluid is detected in the abdomen. The general examination does not show any abnormalities, except for slight pallor and grade 1 digital clubbing. No lymphadenopathy is detected, and the hernial sites are normal.

Figure 1.

A complete blood cell (CBC) count reveals a hemoglobin of 10.7 g/dL (107 g/L), a hematocrit of 32% (0.32), and a red blood cell (RBC) count of 3.5 × 106/µL (3.5 × 1012/L). The liver function tests, kidney function tests, electrolyte panel, and coagulation profile, as well as the remainder of the CBC, are all normal. A routine urine examination shows 3-4 white blood cells (WBCs) per high power field, with no RBCs. A urine culture is performed; within 48 hours, over 100,000 colony forming units/mL of Escherichia coli sensitive to ciprofloxacin, gatifloxacin, gentamicin, and amikacin are found.

An intravenous urogram is ordered (Figure 1).

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