Hematology Pediatric Case Study

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Hematology Pediatric Case Study

Instructions: This case study consists of a hypothetical patient situation. After reading the case study document, you are to complete the case study related to this patient. You will use outside materials to support your assignment. Peer reviewed articles. Please Do Not Use Up To Date. Please use peer-review appropriate source to cite case study. Please

A. ASSESSMENT
: Please provide three Differential Diagnoses with cited rationale —list two (2) with ICD-10 codes and description associated with codes.

1. Differential Diagnosis #1 and cited rationale.
a. ICD-10 codes and descriptions associated with codes

2. Differential Diagnosis #2 and cited rationale.
a. ICD-10 codes and descriptions associated with codes

3. Differential Diagnosis #3 and cited rationale.
a. ICD-10 codes and descriptions associated with codes

B: Medical Diagnosis with cited rationale—list two (2) with ICD-10 codes and description associated with codes.

1. Medical Diagnosis with cited rationale

a. ICD-10 codes and descriptions associated with codes

2. Medical Diagnosis with cited rationale
a. ICD-10 codes and descriptions associated with codes

C. PLAN • Prescriptions: dosage, route, direction / instruction. • Non-Pharmacological- Referrals required (if applicable) • Return to clinic (RTC) in what time frame and reason for next visit/Interventions
About the Patient:
J.T. is a 35-month-old male who presents to your outpatient clinic due to parental concern that he “looks pale.” Mom is here with J.T. and states that they visited her parents this past weekend and maternal grandmother noted that J.T. looked pale.
His past medical history reveals no hospitalizations, surgeries, allergies, or current medications. Immunizations are up to date including the influenza vaccine for the current season. Last well child check was 2 years of age and J. T. met all developmental milestones. His lead level was undetectable and hemoglobin was 11.7 g/dL at 12 months of age.
His social history includes that he attends daycare three mornings a week and otherwise stays at home with mom. Lives at home with both parents and his 12-month-old sister. There is no concern with food availability, no exposure to smoke and no pets in the household.
His dietary history includes preferring to snack all day but does sit and eat with the family at least once a day. J.T. drinks some water and about 48 ounces of 1% milk per day and uses a bottle only for naps and bedtime.
His family history is unremarkable for Mom, Dad, and maternal and paternal grandparents. All are living and well and take no medications routinely.
His vital signs at present: Height: 38 inches (75th percentile) Weight: 30 lbs. (50th percentile) BMI: 14.6; BP 98/50; P: 90; RR 24. Temp: 98.1F.
Physical Exam:
• Constitutional: active child, playful with sibling
• Cardiovascular: no murmur noted, peripheral and central pulses strong and equal.
• Abdomen: soft and rounded, active bowel sounds in all quadrants, no masses or hepatosplenomegaly noted upon palpation.
• Oral: brown spotting noted to upper teeth, gum-line with no bleeding
• Integumentary: no rashes, no bruising or bleeding. Pale mucous membranes.
• Previous labs at 12 months of age included lead level “undetectable” and hemoglobin of 11.7 g/dL. CBC results today:
Parameter (Unit) Value Reference range
Hemoglobin (g/dL) 8.0 10.2-12.7
Hematocrit (%) 25.0 31.0-37.7
MCV (fL) 50 71.3-84.0
RDW (%) 17.0 12.5-14.9
RBC count (106 cells/μL) 3.00 3.89-4.97
WBC count (103 cells/μL) 7.0 5.1-13.4
Platelets (103 cells/μL) 347 202-403

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