Adolescent Female with Fatigue and Dyspnea, Suspected Iron Deficiency Anemia
Case at a Glance
A 15-year-old female with a family history of iron deficiency and a personal history of menorrhagia presented with several months of fatigue, dyspnea, and dizziness. A point-of-care test indicated low ferritin, prompting further investigation.
Patient's Story
The patient is a 15-year-old female who presented with her mother to the clinic with concerns of progressive fatigue, shortness of breath upon exertion, intermittent dizziness, and noticeable pallor. These symptoms began approximately six months prior and have gradually worsened. She has a history of heavy menstrual periods (menorrhagia). Her family history is significant for iron deficiency. The patient has a known history of Obsessive-Compulsive Disorder (OCD), for which she is treated with sertraline. She is a non-smoker but is exposed to secondhand smoke at home. There are no other significant prior health issues. She reports actively trying to lose weight and has lost approximately 8 lbs over the past few months.
Initial Assessment
Upon initial presentation at a local hospital clinic, the patient appeared fatigued and pale. Her height was recorded as 5'6" and weight as 164 lbs. Given the constellation of symptoms and her history of menorrhagia, an initial point-of-care test was performed. A finger-prick blood sample revealed low ferritin levels, raising strong suspicion for iron deficiency.
The Diagnostic Journey
Based on the preliminary low ferritin result and the compelling clinical picture, a formal venous blood draw was scheduled for the following week to confirm the diagnosis and assess the severity. The planned laboratory workup included a Complete Blood Count (CBC) with differential, and a full iron panel (serum iron, ferritin, Total Iron-Binding Capacity, and transferrin saturation). The patient expressed significant anxiety and fear of needles (trypanophobia) and was concerned about the potential for pain and bruising following the procedure.
Final Diagnosis
Pending laboratory confirmation, the provisional diagnosis is Iron Deficiency Anemia, likely secondary to menorrhagia and potentially influenced by familial predisposition.
Treatment Plan
The immediate plan is diagnostic. The patient was counseled regarding the upcoming phlebotomy procedure to help alleviate her anxiety. To address her concerns about post-procedure bruising, she was given specific instructions on aftercare. She was advised to apply immediate, firm, and sustained pressure to the puncture site for 1-2 minutes after the needle is removed. It was explained that this helps the small vessel to clot effectively. She was also counseled to avoid lifting heavy objects or putting significant strain on the arm for a few hours post-procedure to minimize the risk of hematoma formation. A definitive treatment plan, likely involving oral iron supplementation and potential investigation into managing her menorrhagia, will be formulated upon review of the blood test results.
Outcome and Follow-up
The patient is scheduled for a follow-up appointment to discuss the results of her blood tests. The outcome is dependent on these results. Long-term follow-up will focus on monitoring her hematological parameters, ensuring symptomatic improvement with treatment, and managing the underlying cause of her iron deficiency.