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: You see a 44-year-old woman with a 6-month history of increasing fatigue despite adequate opportunity for sleep and rest. Laboratory results reveal a microcytic, hypochromic anemia with an elevated RDW, as well as TSH within normal limits. You expect to find which of the following on review of the patient's health history: 

A: Report that she has been consuming a plant-based diet since age 18. 

B: Report of menorrhagia. 

C: A history of alcohol use disorder.  

D: A diagnosis of rheumatoid arthritis.  

And the correct answer is B: Report of menorrhagia. Where should you start? First determine what kind of a question this is. Given we're being asked to gather additional information, this is an assessment question. This question actually has an interesting format where we're being given the results of her lab testing, and it's described verbally rather than in numeric values. 

What's expected in a question like this, is where the stem or the story of the question is that you're able to read this verbal description of her lab values and then interpret the information. Next step would be to analyze and synthesize these data to help arrive at the correct answer. I've said it before and I'm going to say it again. 

Common diseases occur commonly. Like the most common reason worldwide for the development of anemia is iron deficiency, with the resulting lab results as follows: microcytic, so low MCV; hypochromic, so low MCHC, cells with new cells being different size when compared to the old cells; elevated RDW, so, the new cells in any evolving iron deficiency anemia are even more iron-poor. 

Therefore, they're even smaller than the existing cells. Recall that 90% of the red blood cell is hemoglobin. And what makes up hemoglobin? Heme, iron, globin, protein. And heme, or iron, is what gives the red blood cell its characteristic red color. Because an estimated 8 years of poor iron intake is needed before adults will develop iron deficiency anemia, diet is rarely a cause of IDA in many parts of the world, including North America. 

In fact, really throughout the lifespan from about age 4 up, an insufficient diet is rarely the cause of iron deficiency anemia. So, then what is the most likely cause of iron deficiency anemia? It's usually chronic, low volume blood loss causing a wasting of the red blood cells’ recyclable iron. And where does about 80% of the iron that's in your body right now come from?  

Your body recycling the contents of your red blood cells. Going back to the stem, or the story of the question. You should look at the information given and interpret that with the normal THS, thyroid dysfunction been eliminated as the cause of her fatigue. And we're also told she's had adequate opportunity for sleep and rest. Of course, not sleeping or resting adequately is a common fatigue-contributor in this scenario.  

Likely the heavy menses is the culprit, with the resulting IDA in the patient’s reported fatigue. At the same time, obviously, you need to take a look at the other option. With that, go back to the question. So, you see a 44-year-old woman with a 6-month history of increasing fatigue despite adequate opportunity for rest and sleep, laboratory results reveal a microcytic, hypochromic anemia with an elevated RDW, as well as her TSH is within normal limits. 

You do expect to find which of the following upon review of the patient's health history? A: Report that she has been consuming a plant-based diet since age 18. This is incorrect. Plant-based diet can pose a risk for B12 deficiency, particularly if attention is not given to including B12-rich or supplemented foods such as nutritional yeast and certain vegan melts into the diet. 

If there was B12 deficiency, however, it would result in, of course, a macrocytic, normochromic anemia with an elevated RDW. That said, any anemia type as a result of a nutritionally balanced plant-based diet is quite rare. Even iron deficiency is quite rare in people eating a well-balanced plant-based diet because leafy greens, lentils, beans, and a number of other foods are actually fairly iron-rich. 

B: Report of menorrhagia. This is of course, is the correct answer. Heavy menstrual flow, as part of abnormal uterine bleeding, can result in the loss of approximately 80 milliliters (ml) of blood through a menstrual period, which is about 3 to 4 times that of an average period. Chronic low volume blood loss, as I said earlier, is the most common cause of iron deficiency anemia in this case. 

Well, the blood loss is not daily for this woman. It would be cyclic, occurring monthly. The other part is she is entering that perimenopausal period age-wise, and a lot of times women will have heavy menses for the very first time. What would you do when seeing a patient like this with heavy menses and resulting iron deficiency anemia? 

Obviously, you're going to treat the iron deficiency anemia. But also remember the very, very, very first charge of treating any anemia is to treat the underlying cause. So, help her get those heavy menses under control. C: A history of alcohol use disorder. This is incorrect. Heavy alcohol use classified as three or more drinks per day for a woman, five or more drinks a day for the men, can result in mild microcytosis, usually without anemia, and usually the RDW is normal. 

A drink, if you'll recall, is quantified as 1.5oz of hard liquor like whiskey, vodka, something like that. Five ounces of wine or 12oz of beer. And keep in mind, what would you see if you did have somebody who is drinking heavily? You would likely see a mild macrocytosis. MCV normal is usually about 80 to 96, would probably be like 100 105. 

And that's noted with the heavy alcohol use. Discontinuing the alcohol use and that MCV will go back to a more normal reading over a few months. And then option D: A diagnosis of rheumatoid arthritis. This is, of course, also not correct. RA is a chronic systemic inflammatory disease. In particular, when this disease flares or is not well-controlled, anemia of chronic disease, it's often abbreviated ACD, can occur. 

Given the etiology of this anemia is hypo-proliferation, in other words, just not making as many red blood cells as is normal and not a nutritional deficiency, the hemogram results is normocytic, normochromic with a normal limit RDW. 

Key takeaway: knowing risk factor-specific health problems, including anemia, are key to clinical decision-making and NP board success.  

Voiceover: Thank you for listening to NP certification Q&A presented by Fitzgerald Health Education Associates. 

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