A 7-year-old girl is brought to the emergency department due to leg pain. Two weeks ago, the mother noticed the child walking with a slight limp after playing in the backyard. The limp has worsened, and today the patient refuses to walk. Her energy level has decreased, but the mother attributed this to a poor diet. The patient has autism and limits her diet to only a few items, mainly chocolate milk and crackers. Vaccinations are up to date. Temperature is 98.6 F (37 C). Examination shows scattered erythematous, red macules that do not blanche on bilateral lower extremities. There is tenderness in the thighs with palpation. The patient does not want to move either leg and cries when attempting to stand. Examination of the oropharynx shows inflammation with edema and bleeding along the gums. The neck is supple, and there is no lymphadenopathy. Cardiopulmonary examination is unremarkable. The abdomen is soft without organomegaly. Laboratory results are as follows:Complete blood countHemoglobin 8.7 g/dLMean corpuscular volume (MCV) 70 µm3Reticulocytes 1%Platelets 250,000/mm3Leukocytes 6,800/mm3Coagulation studiesProthrombin time (PT) 12 secActivated partial thromboplastin time (PTT) 30 secWhich of the following is the best next step in evaluation of this patient?
Question
A 7-year-old girl is brought to the emergency department due to leg pain. Two weeks ago, the mother noticed the child walking with a slight limp after playing in the backyard. The limp has worsened, and today the patient refuses to walk. Her energy level has decreased, but the mother attributed this to a poor diet. The patient has autism and limits her diet to only a few items, mainly chocolate milk and crackers. Vaccinations are up to date. Temperature is 98.6 F (37 C). Examination shows scattered erythematous, red macules that do not blanche on bilateral lower extremities. There is tenderness in the thighs with palpation. The patient does not want to move either leg and cries when attempting to stand. Examination of the oropharynx shows inflammation with edema and bleeding along the gums. The neck is supple, and there is no lymphadenopathy. Cardiopulmonary examination is unremarkable. The abdomen is soft without organomegaly. Laboratory results are as follows:Complete blood countHemoglobin 8.7 g/dLMean corpuscular volume (MCV) 70 µm3Reticulocytes 1%Platelets 250,000/mm3Leukocytes 6,800/mm3Coagulation studiesProthrombin time (PT) 12 secActivated partial thromboplastin time (PTT) 30 secWhich of the following is the best next step in evaluation of this patient?
Solution
The symptoms and lab results presented suggest that the child may be suffering from iron deficiency anemia. This is indicated by the low hemoglobin and mean corpuscular volume (MCV), as well as the child's restricted diet which is likely low in iron. The erythematous, red macules on the lower extremities, inflammation, edema and bleeding along the gums could be signs of scurvy, which is caused by vitamin C deficiency. This could also be a result of the child's restricted diet.
The best next step in evaluating this patient would be to perform a serum ferritin test and a vitamin C level test. The serum ferritin test can help confirm the diagnosis of iron deficiency anemia, as ferritin levels are typically low in this condition. The vitamin C level test can help confirm the diagnosis of scurvy, as vitamin C levels are typically low in this condition.
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