Fatigue In A Collegiate Volleyball Player

HISTORY 18yo freshman female volleyball player (starting libero), presents to training room for fatigue. She is from several states away but she reported on evaluation she had struggled with iron deficiency and had previously been evaluated by her PCP. She was not taking any supplements. She reports worsening fatigue over the previous several months, dating back to the end of her senior season. She has been working with her ATc on her conditioning, as she has been dealing with fatigue towards the end of each game/practice, symptoms were thought to be related to adjusting to collegiate athletics/new environment. She reported a single episode of hematochezia, specifically a small amount of blood on toilet paper with wiping, but no further hematochezia or melena. She reports regular menstrual cycles each month, not increasing in duration. She denies fevers, chills, nausea, vomiting, hematemesis, abdominal pain, diarrhea, headaches, sore throat, swollen glands. She denies sick contacts, mood changes, and reports that she has adjusted well to her new college. She has been doing well in classes. She does not adhere to any specific diet. She has not lost or gained any significant weight. PHYSICAL EXAMINATION Gen: Well appearing, no acute distressHEENT: Mild conjunctival pallor, no scleral icterus, no tonsillar enlargement, no tonsillar erythema/exudateNo cervical adenopathy or post auricular adenopathyCV: RRR, no M/R/GAbd: Soft, non-tender, non-distended. No hepatosplenomegaly. DIFFERENTIAL DIAGNOSIS GI bleed, Iron deficiency/Anemia, Malignancy (leukemia/lymphoma), Infectious Mononucleosis, Thyroid dysfunction, Nutritional deficiency/disordered eating, Deconditioning, Depression TESTS AND RESULTS -CBC-Hgb 4.4/Hct 15.9, WBC 3.4, Plt 106, MCV 63, MCH 17.3 -Iron Panel - Ferritin 2, Iron concentration < 10-Reticulocytes -1.9% -LDH, Haptoglobin-WNL -Flow Cytometry - Negative for malignancy FINAL WORKING DIAGNOSIS Symptomatic Anemia secondary to severe iron deficiency TREATMENT AND OUTCOMES Patient was admitted to the hospital for a full hematologic workup given appearance of pancytopenia. She received 4u PRBC as well as 5 days of IV Venofer, with improvement such that on discharge she had Hgb 11.5, WBC 5.7 and Plt 664. She had negative CTAP, negative celiac panel, and plan for outpatient GI workup.