Patient Case Presentation

Patient Overview

M.J. is a 25-year-old, African American female presenting to her PCP with complaints of fatigue, weakness, and shortness of breath with minimal activity. Her friends and family have told her she appears pale, and combined with her recent symptoms she has decided to get checked out. She also states that she has noticed her hair and fingernails becoming extremely thin and brittle, causing even more concern. The patient first started noticing these symptoms a few months ago and they have been getting progressively worse. Upon initial assessment, her mucosal membranes and conjunctivae are pale. She denies pain at this time, but describes an intermittent dry, soreness of her tongue.

Vital Signs:

Temperature – 37 C (98.8 F)

HR – 95

RR- 18

BP – 110/70 (83)

Lab Values:

Hgb- 7 g/dL

Serum Iron – 40 mcg/dL

Transferrin Saturation – 15%

Medical History

  • Diagnosed with peptic ulcer disease at age 21 – controlled with PPI pharmacotherapy
  • IUD placement 3 months ago – reports an increase in menstrual bleeding since placement

Surgical History

  • No past surgical history reported

Family History

  • Mother alive at 50 years old
    • Diagnosis of iron deficiency anemia at 24 years old during pregnancy with patient – on daily supplement
    • Otherwise healthy
  • Father alive at 52 years old
    • Diagnosis of hypertension – controlled with diet and exercise
    • Otherwise healthy
  • No siblings


Social History

  • Vegetarian – patient states she has been having weird cravings for ice cubes lately
  • Living alone in an apartment close to work in a lower-income community
  • Works full time at a clothing department store