Common Clinical Presentation

Which of the following is most consistent with the clinical presentation of a person with folate-deficiency anemia? 

A. A 45-year-old woman with uterine fibroids, menorrhagia and a microcytic, hypochromic anemia with elevated RDW 

B. A 35-year-old woman with newly diagnosed systemic lupus and a normocytic, normochromic anemia with NL RDW 

C. A 40-year-old woman with alcohol use disorder who drinks 5-6 glasses of wine per day and a macrocytic normocytic anemia with an elevated RDW 

D. A 65 yo woman with a 20 year-history of hypothyroidism presenting with a 6-month history of stocking-glove neuropathy and a macrocytic, normochromic anemia with an elevated RDW.  

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Transcript

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: Which of the following is most consistent with the clinical presentation of a person with folate deficiency anemia?  

A: A 45-year-old woman with uterine fibroids and menorrhagia who presents with a microcytic hypochromic anemia with an elevated RDW. 

B: A 35-year-old woman with newly diagnosed systemic lupus and a normocytic, normochromic anemia with a normal limit RDW. 

C: A 40-year-old woman with alcohol use disorder who drinks 5 to 6 glasses of wine per day, and a macrocytic, normochromic anemia with an elevated RDW. 

D: A 65-year-old woman with a 20-year history of hypothyroidism, presenting with a 6-month history of stocking glove neuropathy and a macrocytic normochromic anemia with an elevated RDW. 

The correct answer is C: A 40-year-old woman with alcohol use disorder who drinks 5 to 6 glasses of wine per day, presenting with a macrocytic, normochromic anemia with an elevated RDW. Where do you start? First, determine what kind of a question this is. This is a question that could be categorized as either assessment or diagnosis. 

And the reason I hesitate on saying which one of the two it is, is the fact that anemia is technically not a diagnosis, but more part of the clinical presentation of an underlying condition. I know this is really confusing because we, of course, have abundant ICD-10 codes related to anemia. But let's get back to the issue at hand. 

One more aside on that one. If you ever say differential diagnosis of anemia, somebody might catch you on it and say no, anemia is more an assessment than a diagnosis. Sometimes I think we need to just move on and take care of patients. All right. Back to the issue at hand. A bit of background information on folate deficiency anemia aka folic acid deficiency anemia, sometimes abbreviated FA. Folic acid deficiency anemia.  

Folic acid is a B vitamin. In particular, it's vitamin B9 that's essential to the production of healthy red blood cells. Its role in RBC production is to support DNA synthesis, cell division, and maturation of RBCs in the bone marrow. In this country, folate deficiency or folic acid deficiency from diet alone is relatively uncommon. This is in part due to wheat flour being folic acid supplemented, something that's been done for many decades. 

The majority of people in this country eat enough bread, pasta or similar products that contain wheat flour to give the minimum requirement of folic acid, and then additional folic acid will come from dietary sources such as fruits and vegetables. For individuals who are unable to ingest wheat flour, such as those with celiac disease or gluten intolerance, most substitute flours will also be folic acid supplemented. 

So why do we have here a clinical scenario where we have a person with folate deficiency anemia? As with all anemias, there’ll be specific risk factors for the condition. In the correct answer the person has a major risk factor for this condition, which is a heavy alcohol intake in the presence of problematic alcohol drinking. Last, folic acid is absorbed from dietary sources and more folic acid is wasted through the urine. 

In addition, often the person who is drinking alcohol in excess will be prioritizing alcohol intake rather than the ingestion of food, particularly the types of food that tend to be naturally high in folic acid. When folic acid deficiency is seen with diet alone, it's most common in people who have limited access to fresh fruits and vegetables and might be eating food that is overcooked. 

I often think of my years when I was working with the visiting nurses and going in and doing home care. My background before I became an NP was in critical care, but I also did a very significant stint in home care as a sidekick, and what I would see is my patients got meals delivered to them through programs like Meals on Wheels. 

By the way, I'm a big fan of this program and appreciate Meals on Wheels. It's significant role in helping people who have challenge accessing food at the same time. A person would get a single meal delivered to them, and more often than not, I saw the patient divide that one meal into three different meals and reheat it. Reheat it three times so they'd have a bit for breakfast, a bit at midday, and then the rest for dinner so there'd be vegetables in that meal, but the vegetables would have been cooked three times by the time the last meal was ingested. 

In addition, people with decreased ability to absorb folic acid that occurs in malabsorption syndrome, such as sprue or celiac disease, are increased risk for folic acid deficiency. I'll address the issue of folic acid supplementation and folic acid deficiency in pregnancy and lactation in a future podcast. That's its own whole subject and is important to know for the family and getting ready for board. 

In addition, with all anemia types, the first step is to evaluate the patient's risk for a given type of anemia and then take a look at the hemogram or the CBC with RBC indices. In addition, the next step testing has to be conducted to confirm the cause of the anemia. With these points in mind, let's take another look at the question in the possible answers. 

Which of the following is most consistent with the clinical presentation of a person with folate deficiency anemia? A 45-year-old woman with uterine fibroids, menorrhagia, and microcytic hypochromic anemia with an elevated RDW. This is, of course, incorrect. Take a look at our risk factors then. Menorrhagia heavy menses is a common form of chronic low volume blood loss. 

As you recall, about 90% of the iron in a person's body comes from the recycled contents of old red blood cells. And when these red blood cells hit their 98-, maybe 120-day lifespan, since the body breaks them down, pulls out the iron and recycles it. Therefore, chronic low volume blood loss is the most common reason for iron deficiency anemia in the adult population. 

It is not an iron poor diet, not the hemogram. Results with iron deficiency anemia include a microcytic, hypochromic anemia with an elevated RDW, and in other words, the red blood cells are small and pale due to lack of iron, and the new cells are even smaller and paler than the old cells reflected in the elevated RDW. 

B: A 35-year-old woman with newly diagnosed systemic lupus, an normocytic normochromic anemia with a normal limit RDW. One more time. Keep in mind risk factors, because here we are told that a woman has newly diagnosed systemic lupus. And what do we need to remember about lupus? It's a systemic inflammatory disease that's autoimmune in nature. 

Her anemia is normocytic, normochromic, with a normal limit RDW. In other words, her red blood cells are normal size, normal color, and they're all within the appropriate size range. She is not developing a microcytic or macrocytic anemia. This clinical scenario is consistent with anemia of chronic disease, where the underlying cause is just something along these lines a systemic inflammatory disease. 

One last reminder. Whenever you've got a normocytic, normochromic anemia within normal limit RDW, those red blood cells were made under ordinary circumstances with enough iron, B12 or a folate deficiency. So, this is the scenario of anemia of chronic disease. And as it is with any other anemia as it is with the woman with the iron deficiency anemia, your first line therapy: treat the underlying cause. 

C: A 40-year-old woman with alcohol use disorder who drinks 5 to 6 glasses of wine with a macrocytic, normochromic anemia with an elevated RDW. This, of course, is the correct answer. What is your risk factor for folic acid deficiency? It's excessive alcohol intake. Her red blood cells are macrocytic and large, but normal in color, normochromic.  

Because iron deficiency is not part of the problem, her new red blood cells are even more macrocytic due to the fact that the folic acid deficiency is ongoing, and this is reflected in the elevated RDW. Follow up testing to confirm the reason for her macrocytic anemia should include a serum vitamin B12 and RBC folate. Now, C was our correct answer, but we're going to wrap up and take a look at D: A 65-year-old woman with a 20-year history of hypothyroidism, presenting with a 6-month history of stocking glove neuropathy and a macrocytic, normochromic anemia with an elevated RDW. 

All right. Here we are. We're in a situation where this question where we are given two macrocytic, normochromic anemia with an elevated RDW. And now we have to figure out which one is folate deficiency and which one is not. I want to draw your attention to key points in this clinical scenario. First, there's no mention in option D of a patient having any risk profile link deficiency. 

Another, she has a history of autoimmune disease hypothyroidism, which puts her at higher risk for other autoimmune diseases. In addition, this is the classic presentation of pernicious anemia, which is a form of vitamin B12 deficiency. When comparing pernicious anemia to folate deficiency anemia, pernicious anemia almost always comes along with neurological findings like her stocking glove neuropathy, as well as a more profound anemia when compared to folate deficiency anemia. 

In addition, with pernicious anemia-and we're not giving her full hemogram results, but usually pernicious anemia or vitamin B12 deficiency gives you the most macrocytic of the macrocytic anemias to just kind of wrap this up with folate deficiency anemia. If the upper limits of normal for MCV are around 96 with folate deficiency, you'll probably find it around 105 with pernicious anemia. 

You'll probably find it like around 120, 125. Okay. And given that folic acid and B12 deficiency often do go hand in hand, testing for macrocytic anemia typically includes evaluation of both conditions one more time, getting that serum B12 in the RBC folate. Key takeaway as I've mentioned many times, I always look for groups that are most at risk for a given clinical condition. 

This is the key to honing your clinical decision-making skills, which are the backbone of NP board success. 

Voiceover: Thank you for listening to NP certification Q&A presented by Fitzgerald Health Education Associates. Please rate, review, and subscribe to this podcast, and for more NP resources, visit fhea.com.