What is the evaluation and management approach for a 20-year-old female with a year-long history of fatigue, easy bruising, and nausea?

From the Guidelines

The evaluation and management approach for a 20-year-old female with a year-long history of fatigue, easy bruising, and nausea should begin with a comprehensive medical history and physical examination, followed by laboratory testing, prioritizing the assessment of fatigue severity, impact, and coping strategies, as recommended by the 2023 EULAR guidelines 1.

Initial Evaluation

The initial laboratory workup should include:

• A complete blood count to assess for anemia or thrombocytopenia
• Comprehensive metabolic panel to evaluate liver and kidney function
• Coagulation studies
• Thyroid function tests Given the easy bruising, a platelet count and function assessment is essential, as individuals with easy bruising are at risk for thrombocytopenia or von Willebrand disease, as noted in the cardio-facio-cutaneous syndrome guidelines 1.

Additional Tests and Evaluations

Additional tests may include:

• Vitamin B12, folate, and iron studies to rule out nutritional deficiencies
• If menorrhagia is present, a gynecological evaluation may be warranted
• Depending on the findings, bone marrow examination might be necessary to rule out hematological disorders like leukemia or aplastic anemia

Management Approach

Management will be directed by the underlying cause; for example:

• Iron deficiency anemia would be treated with oral iron supplements such as ferrous sulfate 325 mg daily
• Autoimmune conditions might require immunosuppressive therapy Supportive care should include adequate hydration, nutritional support, and symptom management, with regular assessment of fatigue severity, impact, and coping strategies, and consideration of tailored physical activity interventions and psychoeducational interventions, as recommended by the 2023 EULAR guidelines 1.

Considerations

This constellation of symptoms could indicate various conditions ranging from hematologic disorders to chronic infections, autoimmune diseases, or malignancies, making a systematic approach to diagnosis crucial before initiating specific treatment, and highlighting the importance of shared decision-making between healthcare professionals and patients in managing fatigue and other symptoms 1.

From the FDA Drug Label

PRECAUTIONS General Vitamin B12 deficiency that is allowed to progress for longer than 3 months may produce permanent degenerative lesions of the spinal cord. Laboratory Tests During the initial treatment of patients with pernicious anemia, serum potassium must be observed closely the first 48 hours and potassium replaced if necessary Hematocrit, reticulocyte count, vitamin B12, folate and iron levels should be obtained prior to treatment.

The evaluation and management approach for a 20-year-old female with a year-long history of fatigue, easy bruising, and nausea may involve:

• Laboratory tests: to check for vitamin B12, folate, and iron levels, as well as hematocrit and reticulocyte count 2
• Physical examination: to look for signs of anemia, such as pallor, and to assess overall health
• Medical history: to determine if the patient has any underlying conditions that may be contributing to her symptoms, such as a vegetarian diet or a family history of pernicious anemia
• Differential diagnosis: to consider other potential causes of her symptoms, such as iron deficiency anemia 3 It is essential to approach this patient with a thorough evaluation to determine the underlying cause of her symptoms.

From the Research

Evaluation Approach

The evaluation of a 20-year-old female with a year-long history of fatigue, easy bruising, and nausea involves a comprehensive approach to identify the underlying cause of her symptoms.

• A thorough medical history, including a family history of bleeding disorders, is essential to guide the evaluation process 4, 5.
• Physical examination findings, such as mucocutaneous bleeding, can suggest platelet dysfunction, while hemarthroses or hematomas are more common in coagulopathy 5.
• Initial laboratory testing should include a complete blood count, peripheral blood smear, prothrombin time (PT), international normalized ratio, activated partial thromboplastin time (aPTT), and fibrinogen 4, 5.

Laboratory Testing Interpretation

• Normal PT and aPTT results may indicate a platelet disorder, while a normal PT result with a prolonged aPTT result suggests a disorder of the intrinsic coagulation pathway 4, 5.
• A prolonged PT result with a normal aPTT result may indicate a disorder of the extrinsic coagulation pathway 4, 5.
• Vitamin B12 and folate deficiencies can cause macrocytic anemia and should be considered in the differential diagnosis, especially if the patient has a history of inadequate dietary intake, impaired absorption, or drug ingestion 6.

Further Evaluation and Management

• If initial testing does not reveal an etiology in a patient with a high suspicion for a bleeding disorder, the patient should be referred to a hematologist for additional evaluation 4, 5.
• A bleeding assessment tool, such as the one developed by the International Society on Thrombosis and Hemostasis, can be used to indicate possible pathology 5.
• Consultation with a hematologist is recommended when initial evaluation indicates a bleeding disorder or when suspicion remains high despite a normal laboratory workup result 4.