Question

A 2yr old child is brought to the ED for altered mental status, vomiting, and leathargy.  The parents states that this has been occurring since they moved into their grandmother’s home 2 months ago.  Vitals signs are within normal limits and CBC reveals a hemoglobin – 10.1 mg/dL, mean corpuscular volume (MCV) – 71 fL/cell, and mean cell hemoglobin concentration (MCHC) – 29.1 g/dL. Peripheral smear and abdominal xray are below.

1. What is the most likely diagnosis?
2. What is the next diagnostic step?
3. What is the first step in the management of this patient?