Determine if a referral is needed.

Place your order now for a similar assignment and have exceptional work written by our team of experts, At affordable rates

For This or a Similar Paper Click To Order Now

Analyze this case as you would a client in a clinical setting. You may use your class texts, your pathophysiology text, peer-reviewed journals, and any other reputable sources necessary to help you plan care for this client.
Read the following case study:
Subjective data:
Patient initials: QS
Age: 12 months
Gender: Female
Ethnicity: Caucasian
Allergies: NKDA
Informant: mother
Last Clinic Visit: 1 month ago for right otitis media
Parents/Living status: mother and father living
Siblings (age and gender): no siblings
Family History: MGM with HTN, MGM with hyperlipidemia, MGF with DM
Past Medical History: unremarkable
Past Hospitalizations/Injuries: none
Development/School Issues: no developmental delays
Activities of Daily Living: no daycare, picky eater, taking bottle TID (6 oz.)
Immunizations: current
Current medications: none
Objective data:
Patient presents to clinic today for her 12-months wellness check. Mom has no concerns at this time.
Weight: 19 lbs. 5 oz.
Length: 29.5 inches
Head Circumference: 46 cm
General appearance: well developed, no acute distress, smiling throughout exam
Skin: intact, no rashes or skin lesions
Head: symmetrical
Eyes: + red light reflex, no drainage, minimally pale conjunctiva
Ears: TMs pearly with bilateral clear fluid noted; no auricle tenderness
Nose: bilateral nares clear
Mouth/Throat: free of erythema or exudate
Neck: supple, no LAD
Chest and Lungs: bilateral CTA without wheezing
Heart: RRR without murmurs or gallops
Abdomen: soft, +BS, no hepatosplenomegaly
Musculoskeletal: MAE, taking steps
Neuro: good tone, appropriate throughout exam
CBC was drawn today with the following results:
WBC: 7.3 (4.5-10.5)
LY: 52.0 (20.5-51.1)
MO: 4.7 (1.7-9.3)
GR: 38 (42-75.2)
RBC: 4.13 (4.0-6.0)
HGB: 10.4 (11-18.0)
HCT: 32.0 (35-60)
MCV: 79.0 (80-99)
MCH: 25.7 (27.0-31.0)
MCHC: 32.5 (33.0-37.0)
RDW: 14.2 (11.6-13.7)
PLT: 348 (150-450)
Post a response to the following assessment and plan by 11:59PM (EST) on Thursday:
Assessment:
Provide the diagnosis.
Provide the differential.
Provide rational for this diagnosis.
Plan:
Describe the diagnostic tests ordered (any pending labs go here). This must be supported by the diagnosis and differential.
Provide treatments for this problem (medications and other therapeutic measures). Provide recommendations for this diagnosis only.
Include any health maintenance concerns of immunizations, nutrition, growth and development, and safety. Include anticipatory guidance.
Explain cost concerns with this treatment or community resources.
Recommend a follow-up (when patient should call or RTC).
Determine if a referral is needed.
List references here, and summarize in your own words the current research on this diagnosis and plan of care. List national guidelines used.
Address any sociocultural, financial, or other considerations.
Cite at least 1 relevant article within the last 5 years to support your claim.

Place your order now for a similar assignment and have exceptional work written by our team of experts, At affordable rates

For This or a Similar Paper Click To Order Now

Categories:

No Responses

Leave a Reply

Your email address will not be published. Required fields are marked *