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...

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