Tired on the Golf Course and a Ferritin of 6: Why Iron Deficiency Anemia in a 63-Year-Old Man Is a Gastrointestinal Problem Until Proven Otherwise
[Student Name]
University of Phoenix
NRP/555: Adult and Geriatric Management I
Week 5 Assignment
[Instructor Name]
[Date]
The patient is a composite written for a model paper.
Mr. N., a 63-year-old retired accountant, has felt tired for three months and now has to rest after nine holes of golf, which he used to walk easily. He has no abdominal pain, change in bowel habits, visible blood in the stool or black stools. He eats a varied diet including red meat. He takes low-dose aspirin daily, started by himself "for his heart," and takes naproxen for an arthritic knee on most weekends and some weekdays. His last colonoscopy was 12 years ago and was normal. Laboratory tests show hemoglobin 10.4 g/dL, mean corpuscular volume 74 fL and ferritin 6 ng/mL. This paper explains the evaluation.
Confirming Iron Deficiency
Iron deficiency anemia is the most common cause of anemia worldwide. Camaschella (2015) describes the typical findings: low hemoglobin, small red cells and low iron stores, with ferritin the most useful single test because it reflects stored iron. A very low ferritin, like Mr. N.'s 6 ng/mL, is nearly diagnostic. For anemic patients, the AGA panel favors a ferritin threshold of 45 ng/mL, because higher cutoffs catch more true iron deficiency, especially when inflammation raises ferritin (Ko et al., 2020).
Why the Cause Matters More Than the Number
In a man of 63 who eats meat, iron deficiency almost always reflects blood loss, not poor intake. Goddard et al. (2011) identify slow bleeding from the gut as the leading explanation for iron deficiency anemia in adult men and in women past menopause, and that cancers of the colon and stomach must be excluded. Replacing iron without looking for the cause could let a cancer grow while the anemia improves.
Correcting his hemoglobin without finding where the iron went would fix the number and miss the disease.
The Guideline's Recommendations
The AGA guideline recommends bidirectional endoscopy, colonoscopy and upper endoscopy, for asymptomatic postmenopausal women and men with iron deficiency anemia, rather than no endoscopy (Ko et al., 2020). It also suggests noninvasive testing for celiac disease and for Helicobacter pylori infection, both of which can cause iron deficiency, and advises against routine small bowel evaluation unless the initial endoscopies are unrevealing and anemia persists.
Likely Sources in Mr. N.
Several sources are possible. Aspirin and naproxen can cause gastric or duodenal erosions and ulcers that bleed slowly. Colon polyps or cancer are important in a man overdue for colonoscopy. Angiodysplasia is more common in older adults. Celiac disease, though less likely, causes malabsorption of iron.
Examination
He appears pale. Heart rate 88, blood pressure 128/78 mm Hg, no orthostatic change. Abdomen soft and nontender, no masses or organ enlargement. Rectal examination shows brown stool; a fecal immunochemical test is not ordered, because a negative result would not change the plan and a positive one would not change it either: he needs colonoscopy regardless.
The Plan
I refer Mr. N. for bidirectional endoscopy within weeks. I order tissue transglutaminase antibody with total IgA for celiac disease and a stool antigen test for Helicobacter pylori. I ask him to stop naproxen and to discuss with me whether he needs aspirin, since he has no history of heart disease or stroke and primary prevention aspirin is not generally recommended at his age given bleeding risk. For knee pain, I suggest acetaminophen and a topical anti-inflammatory.
Why Both Ends of the Gut
Men with iron deficiency anemia can have a source in the upper tract, such as an ulcer or gastric cancer, in the lower tract, such as colon cancer or a large polyp, or occasionally in both. Examining only the colon would miss an ulcer caused by his aspirin and naproxen, and examining only the stomach would miss a colon cancer. The two procedures can be done in one session under the same sedation, which is one reason the guideline recommends them together (Ko et al., 2020).
Why Not a Stool Test Instead
Stool tests for blood are designed to screen people without symptoms for colorectal cancer. They are not designed to evaluate iron deficiency anemia, in which bleeding may be intermittent or from the upper tract, where blood is broken down before it reaches the stool. A negative stool test would not end the evaluation, which is why it is not ordered here.
Reviewing the Aspirin Decision
Mr. N. began aspirin on his own after reading that it prevents heart attacks. For people without cardiovascular disease, recent recommendations have moved away from routine aspirin for primary prevention in older adults, because bleeding risk rises with age and may outweigh the benefit. His iron deficiency may be an example of that bleeding risk. I will calculate his cardiovascular risk and discuss whether any aspirin is warranted once the evaluation is complete.
Telling Mr. N. Why
Mr. N. asked whether he could simply take iron and skip the procedures. I explained that iron would help him feel better but could hide a problem that needs treatment, that most causes found are benign and treatable and that finding a colon cancer early, if present, changes outcomes. He agreed to schedule both procedures and asked his wife to drive him on the day.
Iron Replacement
Iron can be replaced while the evaluation proceeds. Camaschella (2015) notes that oral iron is effective and inexpensive, but gastrointestinal side effects are common. I prescribe ferrous sulfate 325 mg once daily or every other day, since alternate-day dosing may improve absorption and tolerance, taken with vitamin C-rich food and away from coffee, tea and calcium. Intravenous iron would be considered if he cannot tolerate or absorb oral iron or if bleeding is ongoing.
Side Effects of Oral Iron
Constipation, nausea and dark stools are common with oral iron. Taking it every other day, with food if needed, often improves tolerance while still raising hemoglobin. I warn Mr. N. that dark stools from iron are expected, but that tarry, sticky black stools with dizziness would suggest bleeding and need urgent care.
Monitoring Response
Hemoglobin should rise by about 1 to 2 g/dL within three to four weeks of adequate iron. I will recheck a complete blood count in four weeks and ferritin after three months, continuing iron for roughly three months beyond a normal hemoglobin so that stores are rebuilt.
What Would Change the Urgency
Black or bloody stools, weight loss, difficulty swallowing, abdominal pain or a falling hemoglobin would require urgent endoscopy or emergency evaluation. I review these with Mr. N.
Conclusion
Mr. N.'s microcytic anemia with a ferritin of 6 ng/mL confirms iron deficiency, and in a 63-year-old man it signals probable gastrointestinal blood loss. Following the AGA guideline, he will have bidirectional endoscopy and noninvasive testing for celiac disease and Helicobacter pylori, stop nonsteroidal anti-inflammatory drugs and start oral iron. The anemia will be corrected, but only the endoscopies can answer the question that matters: where the iron went.
References
Camaschella, C. (2015). Iron-deficiency anemia. New England Journal of Medicine, 372(19), 1832-1843. https://doi.org/10.1056/NEJMra1401038
Goddard, A. F., James, M. W., McIntyre, A. S., & Scott, B. B. (2011). Guidelines for the management of iron deficiency anaemia. Gut, 60(10), 1309-1316. https://doi.org/10.1136/gut.2010.228874
Ko, C. W., Siddique, S. M., Patel, A., Harris, A., Sultan, S., Altayar, O., & Falck-Ytter, Y. (2020). AGA clinical practice guidelines on the gastrointestinal evaluation of iron deficiency anemia. Gastroenterology, 159(3), 1085-1094. https://doi.org/10.1053/j.gastro.2020.06.046
How this NRP 555 Week 5 example is structured
The NRP/555 Week 5 work usually addresses gastrointestinal conditions in adults. This paper shows how a laboratory finding leads to a gastrointestinal evaluation, following the guideline's recommendations step by step and treating the anemia while the cause is found. Students search this week as NRP 555 Week 5, NRP555 Wk 5 or NRP/555 Wk 5; all three are the same assignment.
NRP/555 Week 5 questions, answered
What does NRP/555 Week 5 usually ask for?
Many sections present a gastrointestinal case, such as reflux, abdominal pain or bleeding, and ask for assessment, diagnostic workup and guideline-based management.
Why does iron deficiency in an older man need endoscopy?
Iron deficiency in men and postmenopausal women usually reflects blood loss from the gastrointestinal tract, and cancers of the colon and stomach are important causes, so the AGA recommends bidirectional endoscopy.
What ferritin level indicates iron deficiency?
The AGA guideline suggests a ferritin cutoff of 45 ng/mL in people with anemia to diagnose iron deficiency; very low levels, such as under 15, are highly specific.
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