Lab & Physical Findings In Older Male

Voiceover: Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer.
So, if you're ready, let's jump right in.
Margaret Fitzgerald: A 60-year-old man presents with the chief complaint of a 6-month history of increasing fatigue despite adequate rest and sleep. He denies chest pain or difficulty breathing and reports he's a non-smoker. And currently includes a 25-year history of alcohol use disorder, with daily intake of five to seven, occasionally more, 1.5-ounce shots of whiskey and chronic poor nutrition, stating, “I eat chips a lot. I really can't afford to go out to eat, and I don't have the time to make a meal.”
He's currently employed as a warehouse worker stating, “I get to work every day. I don't think the booze is really a problem.” On physical exam, you note mild pharyngeal redness without exudate, conjunctival pallor, and epigastric tenderness. The following lab results are reported:
Hemoglobin
9 g/dL
(Normal is 14-16 g/dL)
Hematocrit
28.5%
(Normal 42-48%)
RBC
3.4 million mm3
(Normal 4.7-6.1 million mm3)
MCV 108 fL
(Normal 81-96 fL)
MCHC
33.2 g/dL
(Normal 31-37 g/dL)
RDW
18.4%
(Normal 11-15%)
His findings are most likely caused by:
A:
Iron deficiency anemia.
B:
Vitamin B12 deficiency anemia.
C:
Folic acid deficiency anemia.
D:
Anemia of chronic disease.
The correct answer is
C:
Folic acid deficiency anemia. Where do we start? First, determine what kind of question this is. And given that we're provided with lab results to interpret on a person with a fairly complicated health history, this is an assessment question. And of course, what it implies is there's a need for additional laboratory testing. Some background information: The process of red blood cell production takes a number of factors, including adequate amounts of iron, vitamin B12, folic acid, and a number of other trace micronutrients.
When any of these are deficient, anemia can ensue. Folic acid deficiency (FAD) in this country is actually relatively uncommon, and that's in part due to a mandate that wheat flour be supplemented with folic acid. And wheat flour is used in breads, baked products, pasta, things along those lines. However, there are times when there are increased folic acid demands on the body, and folic acid deficiency can occur many times in these podcasts.
I've mentioned that one of the most important points of clinical practice is to be able to identify patients at risk for given conditions. This helps you focus on the problem at hand. The most common causes of folic acid deficiency anemia are inadequate dietary intake, particularly in patients who report a poor diet without the intake of fruits and vegetables, and with accelerated alcohol intake.
Obviously, we have both of these points in this scenario. Heavy alcohol intake, which increases folic acid demands, and poor intake, where the guy's telling us he pretty much eats chips and he doesn't cook and he doesn't have the money to go out to eat. In addition, people with decreased ability to absorb folic acid occurs in malabsorption syndromes such as sprue and celiac disease are an increased risk.
In this patient, as I said, we've got two major risk factors. The hemogram and folic acid deficiency, regardless of cause, reveals a macrocytic, normochromic anemia with an elevated RDW. The degree of anemia in FAD is usually modest, as is the degree of macrocytosis. And of course, this is what we see in this scenario. With suspected folic acid deficiency anemia, of course, confirmatory testing should be done and this would include initial testing or serum levels of folic acid and cobalamin or even better, RBC-folate levels, that's more accurate than serum folic acid.
Cobalamin, of course, is another term for vitamin B12. Deficiency in either of these vitamins can result in a macrocytic, normochromic anemia with an elevated RDW. Given that vitamin B12 deficiency can, as I just mentioned, can also cause macrocytosis with anemia, you might ask why this is not the preferred potential diagnosis in this scenario.
There are a few reasons. One is the heavy alcohol intake; the other is the admittedly poor diet. And last but certainly not least, is that vitamin B12 deficiency, in the form of pernicious anemia, is most often found in older women. This is an autoimmune condition and there's invariably a neurological complaint to go along with it, like change in mentation and numb hands, numb feet. And to boot, with vitamin B12 deficiency, the degree of macrocytosis is quite a bit greater than that seen in folic acid deficiency.
Let's revisit the question. A 60-year-old man presents with the chief complaint of a 6-month history of increasing fatigue despite adequate rest and sleep. He denies chest pain or difficulty breathing and reports he's a non-smoker. Concurrent history includes a 25-year history of alcohol use disorder, with daily intake of 5 to 7, occasionally more, 1.5-ounce shots of whiskey and chronic poor nutrition stating, “I eat chips a lot. I don't have time to make a meal and I can't afford to eat out.”
He is currently employed as a warehouse worker and states, “I get to work every day. The booze is not really a problem.” On physical exam, mild pharyngeal redness without exudate, conjunctiva pallor, and epigastric tenderness are present.
The following recent lab results are noted: Hemoglobin decreased to 9; hematocrit at 28.5%; RBC total reduced to 3.4 million; MCV at 108, so mildly macrocytic; MCHC 33.2, because iron deficiency has nothing to do with this. RDW elevated at 18.4%, telling us the new cells are even more macrocytic than the old cells.
These findings are most likely caused by
A:
Iron deficiency anemia. This is of course incorrect. Iron deficiency anemia (IDA) will present as a microcytic, hypochromic anemia with an elevated RDW. In addition, chronic low-volume blood loss is the most common reason for IDA in the adult population, and we're not given any information about that in this clinical scenario.
I know, I hear the 'yeah, but’ now. ‘Yeah, but alcohol abuse disorder is a risk factor for erosive gastritis, and that could cause chronic low-volume blood loss.’ I'm with you on that one. But if that were true, we would have a microcytic, hypochromic anemia with an elevated RDW. Option
B:
Vitamin B12 deficiency. Again, this is incorrect.
As was mentioned, the most common patient population to develop this type of vitamin deficiency, usually in the form of pernicious anemia, is an older woman. And as I mentioned, usually the degree of anemia is far more severe than what we see with folic acid deficiency, with presenting hemoglobin in the low range of 7 to 8 with neurological complaints like numb hands, numb feet. And as I mentioned earlier, the degree of macrocytosis is quite a bit more with B12 deficiency.
I've seen MCVs as high as 130 in people presenting with pernicious anemia.
C:
Folic acid deficiency anemia. This, of course, is the correct answer. And just to reinforce it one more time, he has two major risk factors for this: poor nutrition and heavy alcohol use.
D:
Anemia of chronic disease. With anemia of chronic disease, this presents as a normocytic, normochromic anemia with a normal limit RDW.
Invariably, if you were being presented with a question where the correct answer was anemia of chronic disease, the reason for the anemia of chronic disease would be mentioned in the question. This could include something like rheumatoid arthritis, systemic lupus, any type of chronic infection, because anemia of chronic disease is most often triggered by chronic systemic inflammation.
Key takeaway, as I've said many times, take a look at the patient case scenario and identify what clinical conditions the person is most likely for developing. This will help push your diagnostic process, which will lead to both clinical and NP board success.
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