An 18-Year-Old with Fatigue, Ice Cravings and a Haemoglobin of 8.4
An 18-year-old II PUC student comes to the PHC with fatigue, breathlessness on climbing two floors and a craving to chew ice. She is a lifelong vegetarian; her family eats rice, sambar and rasam daily but fruit is expensive. A 24-hour recall shows tea and two biscuits at 7 am, nothing until rice and sambar at 1 pm, tea at 4 pm, and rice and rasam at 9 pm; she drinks tea with every meal. Menstrual periods last five days, with pad changes every two hours on days 2 and 3. Examination: BMI 17.8, pale conjunctivae, pulse 104/min. Haemoglobin 8.4 g/dL; the PHC has no ferritin test. She wants an iron injection 'to be strong before practical exams' and asks whether she can just take two iron tablets a day from next month.
1. Give your working classification of her anaemia and explain the factors that most likely contribute. Why is a prescription for iron alone not a complete plan?
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Working classification: moderate anaemia (Hb 8.4 g/dL) with a clinical picture of iron deficiency: fatigue, breathlessness, pallor, pica (ice chewing), low BMI and heavy menstrual bleeding. The blood film would probably be microcytic hypochromic, but ferritin is not available at the PHC.
Contributing factors
- Low dietary iron and poor bioavailability: a rice-based diet, no fruit, and tea with every meal, whose tannins inhibit iron absorption.
- Heavy menstrual loss: pads every 2 hours on days 2-3 suggests menorrhagia, a common cause of iron deficiency in young women.
- Possible worm infestation, common in adolescents in the community.
- Low overall intake and low BMI.
Why iron alone is incomplete: it treats the symptom but not the cause. Heavy menstrual bleeding needs assessment, and worm infestation needs deworming. If she has ongoing blood loss, iron will not correct the Hb. She also needs counselling on diet and tea, and follow-up to check response. Iron injections are not first-line for stable iron deficiency and carry risks.
2. Plan one day of affordable meals using foods available in her area that would improve iron intake and absorption. Explain the pairing choices.
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One-day plan
- Early morning: ragi malt or ragi roti with jaggery; a glass of water. No tea on an empty stomach.
- Breakfast: ragi or jowar roti with groundnut chutney, plus half a lemon or a piece of amla. Vitamin C boosts non-haem iron absorption.
- Mid-morning: sprouted horse gram or green gram chaat with onion and lemon.
- Lunch: rice or ragi mudde, horse gram sambar, a green leafy vegetable palya (spinach, drumstick leaves or amaranth), curd. Keep tea at least one hour after the meal.
- Evening: roasted chana or groundnuts and a citrus fruit; tea only if it is not with the iron-rich meal.
- Dinner: jowar roti, dal or sambar, a vegetable, and a small piece of jaggery.
Reasoning: horse gram, ragi, green leafy vegetables, groundnuts and jaggery are iron-rich and affordable. Lemon, amla and other citrus fruits provide vitamin C. Tea and coffee should be between meals, not with them, because tannins reduce absorption. Curd or calcium should not be the main drink with the iron-rich meal. The plan also increases total energy and protein for her low BMI.
3. She asks for an injection and for two tablets a day. What do you advise, and what red flags would make you refer her urgently?
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Advice on the injection and tablets: do not give or take iron injections without a doctor's assessment. Oral iron is safe and effective for stable iron deficiency; injections are reserved for intolerance, malabsorption or late pregnancy, and can cause reactions. Two tablets a day may be more than prescribed and can cause constipation, nausea and black stools. The correct adult therapeutic dose is usually about 100-120 mg elemental iron daily, with folic acid if prescribed, taken with vitamin C and not with tea. She should be reviewed after 2-4 weeks.
Red flags for urgent referral: breathlessness at rest, chest pain, palpitations, fainting, black or bloody stools, vomiting blood, fever, severe abdominal pain, or bleeding that soaks a pad every hour. Heavy menstrual bleeding that does not respond, or Hb below 7 g/dL, needs referral. Also refer if she cannot swallow, has jaundice, or has no improvement after a proper trial of oral iron.