A 13-Year-Old Girl Is Brought to the Clinic by Her

question 222

Multiple Choice

A 13-year-old girl is brought to the clinic by her parents due to fatigue.  The patient had been well until 2 months ago, when she began the seventh grade.  She has since felt tired most days, especially after walking to classes.  The patient takes no daily medications and follows a well-balanced diet.  Menarche began at age 12, and menstrual cycles occur at 28-day intervals.  Menses last 6-7 days and are sometimes accompanied by abdominal cramping.  Temperature is 37.2 C (99 F) , blood pressure is 105/70 mm Hg, pulse is 100/min, and respirations are 20/min.  Weight is 46 kg (101.4 lb) , which is at the 50th percentile.  Pupils are equal and reactive.  The conjunctivae are pale.  Oropharyngeal examination shows a few brown macules on the lips and buccal mucosa.  The neck is supple with no thyromegaly or lymphadenopathy.  Cardiopulmonary examination is unremarkable.  The abdomen is soft with a normal liver and spleen size.  Distal pulses are 2+.  Results of a complete blood count are as follows: Which of the following is the best next step in management of this patient?

• A)ACTH stimulation test
• B)Bone marrow evaluation
• C)Iron therapy and oral contraception only
• D)Lead level
• E)Upper and lower endoscopy

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