From the Guidelines
The best next step in management for this 13-year-old girl with fatigue is iron therapy and oral contraception only (option C). This patient presents with classic signs of iron deficiency anemia, including fatigue, tachycardia (pulse 100/min), and pale conjunctivae. Her laboratory findings support this diagnosis with a low hemoglobin of 8.4 g/dL and microcytosis (MCV 70 µm3) 1. The most likely cause is heavy menstrual bleeding, as she reports 6-7 day menses, which is longer than average. Iron therapy will address the underlying deficiency by replenishing iron stores needed for hemoglobin synthesis. According to the Centers for Disease Control and Prevention, iron-deficiency anemia can be treated by prescribing 3 mg/kg per day of iron drops to be administered between meals 1. Oral contraceptives will help reduce menstrual blood loss by thinning the endometrial lining. The combination therapy addresses both the immediate anemia and its underlying cause. Other options like ACTH stimulation test, bone marrow evaluation, lead level testing, or endoscopy are not indicated as the clinical picture strongly suggests iron deficiency anemia due to menorrhagia, which is common in adolescent females who have recently started menstruating and have not yet established regular hormonal patterns.
Some key points to consider in the management of this patient include:
- The importance of monitoring the patient's hemoglobin levels regularly to ensure an adequate response to iron therapy 1
- The potential for gastrointestinal side effects with oral iron therapy, and the consideration of alternative formulations such as ferric maltol if necessary 1
- The need for patient education on the importance of adherence to iron therapy and the potential for ongoing menstrual bleeding to exacerbate iron deficiency anemia.
Overall, the treatment of iron deficiency anemia in this patient should prioritize the correction of the underlying iron deficiency, as well as the management of the underlying cause of heavy menstrual bleeding.
From the FDA Drug Label
CONTAINS: Each tablet contains 324 mg of ferrous sulfate, equivalent to 65 mg of elemental iron, providing 362% of the U.S. recommended daily intake (RDI) of iron for adults and children 4 and older. DIRECTIONS FOR USE: Do not crush or chew tablets. Adult Serving Size: 1 tablet two to three times daily. Children: Consult a physician.
The patient's symptoms and laboratory results suggest iron deficiency anemia, given the low hemoglobin level (8.4 g/dL) and mean corpuscular volume (70 µm3). The best next step in management would be to start iron therapy.
- The patient's age and symptoms do not directly indicate a need for oral contraception or other treatments listed.
- Given the patient's pale conjunctivae and low hemoglobin, iron supplementation is a reasonable next step.
- Lead level or bone marrow evaluation may be considered if iron therapy is ineffective or if other symptoms arise, but are not the best initial step.
- Upper and lower endoscopy and ACTH stimulation test are not directly relevant to the patient's current symptoms and laboratory results. The choice C. Iron therapy and oral contraception only is the closest match, but since the labels do not provide information about the use of oral contraception in this context, the decision to use it should be made with caution and considering other factors not mentioned in the labels 2 2.
From the Research
Patient Presentation
The patient is a 13-year-old girl presenting with fatigue, especially after walking to classes. She has a history of well-balanced diet and no daily medications. Her menstrual cycles are regular, and she has no other significant medical history.
Laboratory Results
The patient's complete blood count shows:
- Hemoglobin: 8.4 g/dL
- Mean corpuscular volume: 70 µm3
- Platelets: 180,000/mm3
- Leukocytes: 7,500/mm3
Diagnosis and Management
Based on the patient's symptoms and laboratory results, iron deficiency anemia is a possible diagnosis. The patient's low hemoglobin level and mean corpuscular volume suggest microcytic anemia, which is consistent with iron deficiency anemia 3, 4, 5. The best next step in management would be to initiate iron therapy. Oral iron is typically the first-line treatment for iron deficiency anemia 3, 4, 6. The patient's symptoms and laboratory results do not suggest any contraindications to oral iron therapy.
Treatment Options
The following treatment options are available:
- Oral iron therapy: ferrous sulfate 325 mg/d or on alternate days 3, 4, 6
- Intravenous iron therapy: reserved for patients with intolerance or unresponsiveness to oral iron, or those who require rapid correction of iron deficit 7
Recommended Course of Action
Based on the patient's presentation and laboratory results, the recommended course of action would be to initiate oral iron therapy and monitor the patient's response. If the patient does not respond to oral iron therapy or has contraindications to oral iron, intravenous iron therapy may be considered 3, 4, 6, 7.
Some key points to consider in the management of this patient include: