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M. Gómez de Pablos Romero*, M. Sánchez Martín**
*Adjunto de Pediatría del Hospital Universitario Fundación Alcorcón. **Adjunto de Pediatría del Hospital Universitario La Paz
29. Anemia: outpatient visit
Mother: Good morning, Dr. Robinson. I’m here because Martha has been feeling very tired the last couple of months.
Doctor: Good morning, please have a seat. Let’s see, Martha is 12 years old, and she has no past medical history, right?
Mother: Yes, that’s right.
Doctor: Martha, have you been doing more exercise than usual lately? Are you sleeping well?
Martha: I have been doing the same amount of exercise at school, and I sleep around 7-8 hours a day.
Doctor: Have you been sick lately? Do you take any medication? Have you lost any weight? Have you noticed if you sweat more than usual, especially at night?
Martha: No, I have not been sick, I don’t take any medications, and I haven’t noticed any of those things.
Doctor: Ok, is there any family history of blood problems, thyroid disease or rheumatologic conditions?
Mother: I have thalassemia trait. There is no other relevant family history that I am aware of.
Doctor: Great, Martha, have you had your first period?
Martha: Yes, six months ago. I am still irregular.
Doctor: How often do you have your period? How long does it last? Is it heavy?
Martha: Every three to five weeks, and it lasts about five days. I usually have to change three to four times a day.
Doctor: How about your diet? Is it balanced? Do you eat meat?
Martha: Yes, I love meat, actually.
Doctor: Alright Martha, may I take a look at you?
PHYSICAL EXAMINATION
Pulse: 90 bpm. BP: 115/85 mmHg. SpO2: 99%. Axillary temperature: 36.5ºC. Good general condition. Mild pallor of conjunctiva and oral mucosa. Well-nourished and hydrated. Capillary refill time: less than 2 seconds. No respiratory distress. Cardiac auscultation: regular, no heart murmur. Pulmonary auscultation: normal. Abdomen: normal, no masses or organomegalies. No lymphadenopathies. Rest of physical examination: normal.
Doctor: I notice that Martha’s mucosa is quite pale. She is probably a bit anemic, and that could be why she has been feeling so tired. We’ll do a lab test to confirm it, and rule out other causes.
Mother and Martha: OK, thank you Dr. Robinson.
Two days later Martha comes in for the lab results: RBC: 4.56 x 106/mm3; haemoglobin; 10.8 g/dl; haematocrit; 33.7%; MCV: 74 fl; MCH: 23.7 pg; MCHC: 32 g/dl; platelets: 350,000/ µl; WBC and differential: normal. Ferritin: 8 µg/l; iron: 10 µg /dl; transferrin: 380 mg/dl; TSI: 2.5%; total iron binding capacity: 600 µg/dl. CMP, including LDH and bilirrubin: normal results. TSH: 2.6 µIU/L.
Mother: Good morning, Dr. Robinson, have you received the lab results?
Doctor: Good morning, yes, they just came in. Martha has mild anemia and iron deficiency, which explains her symptoms. Everything else is normal.
Mother: Oh, I’m so relieved! I was worried because I have read about some serious diseases.
Doctor: Well, I’m glad we have figured it out. She must take iron supplements for three months. I’ll make a prescription so that you can buy them.
Mother: How can we be sure that Martha doesn’t have thalassemia trait as well?
Doctor: We’ll repeat the blood test in a month and at the end of the treatment, to make sure that the anemia has resolved itself. If not, we’ll have to perform more specific tests such as hemoglobin electrophoresis, but for now I wouldn’t worry about that.
Mother: OK, thank you Dr. Robinson. I will buy the iron supplements right away.
KEY WORDS:
Lost any weight (to lose weight): perder peso.
Sweat more than usual (to sweat): sudar más de lo habitual.
Thalassemia trait: rasgo talasémico.
First period: primera regla (menarquia).
Heavy (period): regla abundante.
Balanced (diet): dieta equilibrada.
Mild pallor of conjunctiva and oral mucosa: leve palidez de conjuntiva y mucosa oral.
Lymphadenopathies: adenopatías.
Pale: pálida.
RBC (red blood count): recuento de hematíes.
MCV (mean corpuscular volume): volumen corpuscular medio.
MCH (mean corpuscular hemoglobin): hemoglobina corpuscular media.
MCHC (mean corpuscular hemoglobin concentration): concentración de hemoglobina corpuscular media.
WBC (White blood count): recuento de leucocitos.
Differential: fórmula leucocitaria.
Iron: hierro.
TSI (transferrin saturation index): índice de saturación de transferrina.
TIBC (Total iron binding capacity): capacidad total de fijación del hierro.
CMP (comprehensive metabolic panel): bioquímica completa.
Iron deficiency: ferropenia.
Iron supplements: suplementos de hierro.
Prescription: prescripción médica.
Hemoglobin electrophoresis: electroforesis de hemoglobinas.
Syncope 