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Case Study: Iron Deficiency Anemia

Patient Information:

• Name: John Doe

• Age: 35

• Gender: Male

• Occupation: Construction Worker

• Medical History: No significant medical history reported.

Presenting Complaint: John Doe presents to the clinic with complaints of fatigue, weakness,

and shortness of breath on exertion for the past few months. He reports feeling unusually tired,

even after a full night’s sleep, and has noticed increased paleness of his skin and conjunctiva.

Physical Examination Findings:

• Vital Signs: BP 120/80 mmHg, HR 80 bpm, RR 16 breaths/min, Temp 98.6°F

• General: Pale skin and conjunctiva, fatigue apparent

• Cardiovascular: Regular rhythm, no murmurs or abnormal sounds

• Respiratory: Clear lung fields bilaterally

• Abdomen: Soft, non-tender, no organomegaly

• Neurological: Intact cranial nerves, normal motor and sensory functions

Laboratory Investigations:

• Hemoglobin (Hb): 9.5 g/dL (Normal range: 13.5-17.5 g/dL)

• Hematocrit (Hct): 29% (Normal range: 40-50%)

• Mean Corpuscular Volume (MCV): 75 fL (Normal range: 80-100 fL)

• Serum Iron: 25 mcg/dL (Normal range: 60-170 mcg/dL)

• Total Iron Binding Capacity (TIBC): 400 mcg/dL (Normal range: 250-450 mcg/dL)

• Ferritin: 10 ng/mL (Normal range: 30-400 ng/mL)

Diagnosis: John Doe is diagnosed with iron deficiency anemia based on his clinical presentation,

physical examination findings, and laboratory results.

Questions for Students:

1. What are the common signs and symptoms of iron deficiency anemia?

2. Explain the laboratory findings in John Doe’s case and how they support the diagnosis of

iron deficiency anemia.

3. What are the potential causes of iron deficiency anemia in adults, and how would you

approach further investigations in this patient?

4. Discuss the treatment options for iron deficiency anemia, including dietary

recommendations and pharmacological interventions.

 

Case Study: Iron Deficiency Anemia

Patient Information:

• Name: John Doe

• Age: 35

• Gender: Male

• Occupation: Construction Worker

• Medical History: No significant medical history reported.

Presenting Complaint:
John presents to the clinic with complaints of fatigue, weakness, and shortness of breath on exertion over the past few months. He also reports feeling unusually tired despite adequate sleep and notes paleness of skin and conjunctiva.

Physical Examination Findings:

• Vital Signs: BP 120/80 mmHg, HR 80 bpm, RR 16, Temp 98.6°F

• General: Pale skin and conjunctiva, fatigue

• Cardiovascular: Regular rhythm, no murmurs

• Respiratory: Clear lungs

• Abdomen: Soft, non-tender, no organ enlargement

• Neurological: Normal exam

Laboratory Investigations:

• Hemoglobin (Hb): 9.5 g/dL (Low)

• Hematocrit (Hct): 29% (Low)

• MCV: 75 fL (Low – microcytic)

• Serum Iron: 25 mcg/dL (Low)

• TIBC: 400 mcg/dL (High)

• Ferritin: 10 ng/mL (Low)

Diagnosis:
Iron Deficiency Anemia based on clinical presentation, physical findings, and laboratory results.

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Struggling with where to start this assignment? Follow this guide to tackle your assignment easily!

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Step-by-Step Case Study Guide: Iron Deficiency Anemia in John Doe

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Question 1: What are the common signs and symptoms of iron deficiency anemia?

Start by identifying the classic symptoms:

• Fatigue

• Weakness

• Pale skin and conjunctiva

• Shortness of breath, especially with exertion

• Dizziness or lightheadedness

• Cold hands and feet

• Brittle nails or hair loss (in chronic cases)

• Pica (craving non-nutritive substances like ice or dirt)

Link to the case: John shows fatigue, pallor, and shortness of breath—consistent with iron deficiency anemia.

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Question 2: Explain the laboratory findings in John Doe’s case and how they support the diagnosis.

Use this structure to interpret his labs:

Conclusion: These labs are classic for iron deficiency anemia—microcytic, hypochromic anemia with low ferritin and high TIBC.

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Question 3: What are the potential causes of iron deficiency anemia in adults, and how would you approach further investigations in this patient?

Common Causes in Adults:

• Chronic blood loss: GI bleeding (ulcers, colon cancer, hemorrhoids)

• Inadequate dietary intake

• Malabsorption: Celiac disease, gastric bypass

• Increased needs: Heavy physical labor, athletes

Further Workup for John Doe:

• Fecal occult blood test or stool guaiac test

• Colonoscopy or endoscopy if bleeding is suspected

• Dietary assessment

• Consider occupational risks (GI strain from labor, poor diet)

In John’s case, GI blood loss or nutritional deficiency are most likely. Recommend GI evaluation and dietary history.

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Question 4: Discuss the treatment options for iron deficiency anemia, including dietary recommendations and pharmacological interventions.

A. Dietary Recommendations:

• Increase iron-rich foods: red meat, leafy greens, legumes, iron-fortified cereals

• Consume vitamin C with meals to enhance absorption (e.g., citrus fruits)

• Avoid drinking tea/coffee with meals (inhibits iron absorption)

B. Iron Supplementation:

• Oral iron therapy: Ferrous sulfate 325 mg PO daily or TID

• Take on an empty stomach if tolerated

• Common side effects: constipation, nausea, dark stools

C. IV Iron (if needed):

• For patients intolerant to oral iron or with severe anemia

• Consider ferric gluconate or iron sucrose

D. Monitor and Follow-Up:

• Retest Hb and ferritin in 4–6 weeks

• Continue therapy for 3 months after correction to replenish iron stores

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Suggested Peer-Reviewed Sources:

1. Camaschella, C. (2015). Iron-deficiency anemia. The New England Journal of Medicine, 372(19), 1832–1843.

2. Goddard, A. F., et al. (2011). Guidelines for the management of iron deficiency anemia. Gut, 60(10), 1309–1316.

3. Killip, S., et al. (2007). Iron deficiency anemia. American Family Physician, 75(5), 671–678.

4. Tolkien, Z., et al. (2015). Ferrous sulfate supplementation in adults: A meta-analysis. PLoS ONE, 10(2), e0117383.

5. WHO. (2021). Iron deficiency anemia: Assessment, prevention and control. Link

 

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