Radiographic and Other Studies

Chest x-ray. Can diagnose pulmonary infection, mediastinal adenopathy, or pleural effusion.

CT scan or ultrasound. Can be useful in diagnosing infection within abdomen and pelvis, as well as malignant infiltration of lymph nodes, liver, or spleen.

Bone marrow aspirate and biopsy. Should be performed in patients suspected of having a marrow infiltrative disorder; occasionally can be useful in diagnosing certain infectious processes (eg, toxoplasmosis).

Lumbar puncture. Consider in patients with headache or meningismus. Cerebrospinal fluid (CSF) should be sent for cell count, protein, and glucose, as well as culture. If malignancy is a concern, also obtain cytology. If brain abscess, increased intracranial pressure, or mass-occupying lesion is suspected, order head CT scan before obtaining CSF.

V. Plan. The etiology of leukocytosis should guide therapy. Patients with infectious etiologies should be managed with antibiotics, if appropriate, or followed expectantly. Patients in whom appendicitis or abscess are suspected should undergo immediate surgical consultation. Patients with possible malignancy or rheumatologic disorders should be referred to appropriate consultants. Acutely ill patients are admitted to the hospital. When the etiology is not readily identified, despite initiation of an appropriate evaluation, follow-up is critical.

VI. Problem Case Diagnosis. The 7-year-old girl suffered from acute streptococcal pharyngitis. Throat exam showed exudate and palatal petechiae. She had anterior cervical lymphadenopathy, and all nodes were tender and less than 1 cm. Rapid strep test was positive.

VII. Teaching Pearl: Question. CBC is obtained for an apparently healthy, full-term newborn at 12 hours of age. The infant's total WBC count is 23,000/mm3. What action is indicated at this time?

VIII. Teaching Pearl: Answer. No specific action is indicated. The mean WBC count for an infant of this age is 22,800/mm3 (range: 13,000-38,000/mm3).

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Headache Happiness

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