A 62-year-old man comes to the office due to several months of fatigue. The patient has no chest pain, vomiting, diarrhea, weight loss, or back pain. Review of systems is significant for occasional leg cramps. He takes lisinopril for hypertension and atorvastatin for hyperlipidemia. The patient no longer smokes cigarettes but has a 30-pack-year history. He does not consume alcohol. Blood pressure is 132/80 mm Hg and pulse is 95/min. Conjunctiva are pale. Cardiopulmonary auscultation reveals clear lungs and a soft 2/6 ejection murmur at the right upper sternal border. The abdomen is soft and nontender without palpable masses. There are no skin rashes or peripheral edema. Laboratory results are as follows: Which of the following is the most appropriate next step in management of this patient?

Question

A 62-year-old man comes to the office due to several months of fatigue.  The patient has no chest pain, vomiting, diarrhea, weight loss, or back pain.  Review of systems is significant for occasional leg cramps.  He takes lisinopril for hypertension and atorvastatin for hyperlipidemia.  The patient no longer smokes cigarettes but has a 30-pack-year history.  He does not consume alcohol.  Blood pressure is 132/80 mm Hg and pulse is 95/min.  Conjunctiva are pale.  Cardiopulmonary auscultation reveals clear lungs and a soft 2/6 ejection murmur at the right upper sternal border.  The abdomen is soft and nontender without palpable masses.  There are no skin rashes or peripheral edema.  Laboratory results are as follows:  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

This patient has clinical findings (fatigue, pallor, ejection murmur) consistent with anemia and laboratory evidence (low mean corpuscular volume and ferritin) of iron deficiency. Iron is derived from dietary sources (eg, animal meat) and is mostly absorbed in the duodenum. Body iron is distributed to red blood cells (hemoglobin), other iron-containing proteins (eg, myoglobin), and ferritin/hemosiderin in the reticuloendothelial system. In developed countries, iron deficiency rarely stems from dietary or absorption inadequacies. Most cases are due to overt or occult blood loss. History and physical examination can often identify an overt source of bleeding (eg, menorrhagia); otherwise, referral to a gastroenterologist for endoscopic evaluation (eg, colonoscopy, esophagogastroduodenoscopy) is usually required (particularly in those age >50) as patients may have gastritis, telangiectasia, or malignancy (eg, colon cancer). (Choice A) Although bone marrow biopsy is considered the gold standard for assessing iron stores, less invasive testing (eg, ferritin) has largely supplanted this diagnostic modality. Bone marrow biopsy is used primarily to evaluate for hematologic malignancies (eg, myelodysplastic syndrome) and stem cell abnormalities (eg, aplastic anemia). (Choice B) Atorvastatin may cause hepatotoxicity and myopathy but is not associated with iron deficiency anemia. (Choice D) C-reactive protein is usually elevated in infection or inflammatory conditions. Patients with these illnesses often have anemia of chronic disease due to poor iron utilization and impaired erythrocytosis. Anemia of chronic disease is usually associated with normal or high ferritin levels. (Choice E) Erythropoietin (EPO) stimulates erythrocytosis. Low levels of EPO can be seen in many chronic diseases (eg, renal insufficiency). EPO is not often measured, and conditions that result in low EPO are usually associated with anemia of chronic disease (normal or high ferritin levels). (Choice F) Monoclonal light chains can be elevated in plasma cell disorders such as multiple myeloma. Although anemia is common, it is usually normocytic and normochromic (not microcytic). Educational objective: Gastrointestinal blood loss is the most common occult cause of iron deficiency anemia, especially in patients age >50. Referral to a gastroenterologist for endoscopy is usually required.

A 62-Year-Old Man Comes to the Office Due to Several