AKT-0801

A 15-year-old female presents to surgery with her mother. Her mother is worried about her daughter’s persistent fatigue, recurrent coughs and sore throats, and recent appearance of small purple spots on her skin. The patient also reports intermittent feverishness. Blood tests for EBV serology were normal a few weeks ago. On examination, the patient appears pale, with unremarkable observations. There is no lymphadenopathy or hepatosplenomegaly, but small petechiae are present on the torso and arms. Based on NICE guidelines, which finding in the history and examination of this adolescent would warrant immediate specialist evaluation for leukemia?