Evaluating Failure to Thrive in a Toddler

In Episode 37 of Med School Question of the Week for USMLE, Faustine Ramirez, MedSchoolCoach expert tutor, answers this medical school question: A previously healthy 3-year-old boy is brought to the pediatrician’s office by his mother because of 6 months of abdominal pain, intermittent constipation, fatigue and poor weight gain. For the past two weeks he has been walking strangely and seems to slap his right foot on the ground when he takes a step. He is fully immunized and has no significant past medical history. His mother recently returned to work full-time and his grandparents have been taking care of him at their house where he plays with his mother’s old toys. Vital signs are within normal limits. Physical examination reveals a tired appearing boy. He is alert, awake, able to answer your questions and follow simple commands. Heart and lung examinations are unremarkable. Examination of the oropharynx reveals poor dentition and blueish discoloration of the gingivae at the base of his teeth. Abdomen is soft and mildly tender to palpation. No rashes or other skin findings are apparent. Labs are ordered and reveal: hemoglobin 9.8, MCV 64, leukocytes 7,000, platelet count 230,000, serum iron 100, ferritin 80, transferrin saturation 30%. What is the best next step?

• Gluten-free diet
• Prune juice
• Iron supplementation
• Blood transfusion
• Levothyroxine
• Succimer
• Amoxicillin
• Deferoxamine