Health Assessment

Iron Deficiency

Carnel C. Jackson, DNP, RN, FNP-BC

Case Study

Chief Complaint

“I have been so tired these last few months, I have to nap every day.”

Patient Profile

Name: Charles Williams

Age: 59

Gender: male

History of Presenting Illness

C.W. is a 56-year-old man who presents with complaints of progressive fatigue over the past several months.* He reports excessive daytime fatigue, requiring daily naps.* This fatigue has been persistent and has gradually worsened over the last few months. Additionally, Mr. Williams notes an unintentional weight loss of approximately 32 pounds over the past 4 months.* He denies actively trying to lose weight. He is concerned about the rapid and unexplained nature of his weight change.*

He denies any recent illness, fever, night sweats, or infections. He reports no chest pain, palpitations, shortness of breath, or orthopnea. He denies gastrointestinal symptoms, such as nausea, vomiting, diarrhea, or abdominal pain.

He has no known history of anemia, thyroid disease, diabetes, or malignancy.*

Medical History

Seasonal allergies, hypertension, hyperlipidemia, chronic back pain

Medications

  • Loratadine: 10 mg by mouth daily
  • Lisinopril: 10 mg by mouth daily
  • Atorvastatin: 20 mg by mouth daily
  • Meloxicam: 15 mg by mouth daily

Social History

  • Daily walks with his daughter
  • Lives in a two-story home with his wife and dog
  • Alcohol use: rarely
  • Tobacco smoke: prior use in teenage years, nothing since
  • Illicit drug use: none

Family History

  • Mother: Hypertension, diabetes mellitus type 2
  • Father: Colon cancer diagnosed at 52,* alive
  • Maternal grandmother: Hypertension, diabetes mellitus type 2
  • Maternal grandfather: Hypertension
  • Paternal grandfather: Hyperlipidemia, hypertension
  • Paternal grandmother: Unknown

Review of Systems

  • Constitutional: Denies chills, fever. Endorses weight loss (32 pounds in 4 months) and fatigue.
  • HEENT: Denies postnasal drip, sore throat, hearing impairment; denies blurred vision.
  • Respiratory: Denies shortness of breath, cough, wheezing.
  • Cardiovascular: Denies chest pain and pedal edema.
  • Gastrointestinal: Denies abdominal pain, tenderness, nausea, and emesis. Denies constipation, diarrhea, and hematochezia. Endorses decreased appetite. Endorses melena once or twice in the last few months.*
  • Derm: Denies breaks in the skin, lesions, and rashes.
  • Neurological: Denies headaches, tremors. Endorses dizziness intermittently.*
  • Hematologic: Denies easy bruising.

Physical Assessment

General appearance: Alert, oriented, slender male.

Vitals

  • Blood pressure: 122/64 mm Hg
  • Heart rate: 62 bpm
  • Respiratory rate: 16 bpm
  • Temperature: 97.8℉
  • Oxygen saturation: 99% on room air

General Survey

  • HEENT: Dry mucous membranes,* PERRLA. Positive for poor skin turgor,* conjunctival pallor.*
  • Cardiovascular: Normal rhythm without murmurs, normal s1 and s2.
  • Respirations: Clear to auscultation bilaterally.
  • Abdomen: Active bowel sounds x4, mild tenderness to palpation in the epigastric region,* no guarding.
  • Derm: Without abrasion or ulceration. Positive for pallor and brittle nails.
  • Neurological: No focal deficits, no signs of confusion or cognitive impairment.

Diagnostic Testing

Table 1. Mr. William’s Laboratory Results

Substance

Value

Normal Range
Glucose (Fasting) 76 70-99 mg/dL (fasting)
Sodium (Na) 135 136-144 mEq/L
Potassium (K) 3.4 3.4-5.2 mEq/L
Chloride (Cl) 112 96-106 mmol/L
BUN 18 7-20 mg/dL
Creatinine 1.24 0.8-1.4 mg/dL
Calcium (Ca) 8.9 8.5-10.9 mg/dL
Protein (total) 7.1 6.3-7.9 g/dL
Glomerular filtration rate 69 90-120 mL/min/1.73m2
Hematocrit 34%* 35%-44%
Hemoglobin 11.2* 13.8-17.2 g/dL
Ferritin 26* 30-400 ng/mL
TIBC 496* 240-450 mcg/dL
Transferrin Saturation 9* 15%-50%
Heme Occult Stool Positive* Standard-negative

Assessment

Most likely diagnosis

Iron deficiency anemia 2/2 GI bleed

Treatment Plan

  1. Gastroenterology referral:colonoscopy to rule out malignancy
  2. Ferrous sulfate 325 mg by mouth three times weekly
  3. Obtain complete blood count

Review Questions

Click the arrow to expand the section and view the correct answers.

  1. In a patient presenting with fatigue and melena, which objective finding supports iron deficiency? Select all that apply
    1. Pale skin
    2. Dizziness
    3. Conjunctival pallor
    4. Blurred vision
    5. Poor skin turgor
Answer:

A. Pale skin, B. dizziness, C. conjunctival pallor, E. poor skin turgor. Feedback: Pale skin, dizziness, conjunctival pallor, and poor skin turgor are all symptoms of iron deficiency.

  1. When interviewing your patient with iron deficiency, which subjective symptom would warrant more urgent workup?
    1. Fatigue and headaches
    2. Melena
    3. Palpitations and chest pressure
    4. Brittle nails
Answer:

C. Palpitations and chest pressure. Feedback: Fatigue, melena, and brittle nails are all signs of a chronic iron deficiency diagnosis that is consistent with an epigastric cause. Palpitations and chest pressure are considered an urgent concern and require immediate medical attention. Iron deficiency anemia compromises the amount of oxygen rich blood and as a result makes your heart work harder.

  1. Which of the following is not a sign of early onset colorectal cancer?
    1. Abdominal discomfort
    2. Weight loss
    3. Decreased appetite
    4. Hemorrhoids
Answer:

D. Hemorrhoids. Feedback: Hemorrhoids may cause similar symptoms to colorectal cancer, such as discomfort and rectal bleeding. If someone reports ongoing symptoms, they should be evaluated by a gastroenterologist.

  1. Which of the following is the most common clinical symptom associated with iron deficiency anemia?
    1. Bradycardia
    2. Jaundice
    3. Fatigue and weakness
    4. Polyuria
Answer:

C. Fatigue and weakness. Feedback: Iron deficiency anemia reduces the oxygen-carrying capacity of the blood. This leads to symptoms such as fatigue, weakness, pallor, and shortness of breath. Bradycardia, polyuria, and jaundice are not typical symptoms of iron deficiency anemia.

  1. Which of the following is an objective finding commonly seen in patients with iron deficiency anemia during physical examination? Select all that apply
    1. Glossitis
    2. Night sweats
    3. Peripheral edema
    4. Cyanosis of the lips
Answer:

A. Glossitis, B. night sweats, and C. peripheral edema. Feedback: Objective findings in iron deficiency anemia may include glossitis. Night sweats and peripheral edema are not typically seen in iron deficiency anemia and cyanosis is more common in severe hypoxia than anemia specifically.

  1. In an adult male patient, new onset iron deficiency anemia should prompt an evaluation for which of the following conditions? Select all that apply
    1. Peptic ulcer disease
    2. Colon cancer
    3. Hypertension
    4. Post-menopausal menses
Answer:

B. Colon cancer and A. peptic ulcer disease. Feedback: In adults, new onset iron deficiency anemia can be a sign of chronic blood loss, often due to conditions like colon cancer. While peptic ulcer disease can also cause gastrointestinal bleeding, colon cancer is a critical diagnosis to rule out due to its potential mortality and morbidity.

  1. What objective findings support the need to initiate an urgent workup?
    1. Polyuria
    2. Numbness in the feet
    3. Constipation
    4. Brittle nails
Answer:

B. Numbness in the feet. Feedback: Numbness in the feet is a sign of an advanced malignancy and cauda equina should be ruled out immediately. Polyuria is a general symptom that does not require urgent workup.

  1. A 59-year-old male reports fatigue and frequent need for naps. On examination, he has pallor and dry mucous membranes. Which of the following additional assessment findings is most associated with iron deficiency anemia?
    1. Jaundice and easy bruising
    2. Petechiae and dark-colored urine
    3. Smooth, red tongue and cracks at the corners of the mouth
    4. Bone pain and splenomegaly
Answer:

C. Smooth, red tongue and cracks at the corners of the mouth. Feedback: Common findings of iron deficiency anemia include glossitis, angular cheilitis, brittle nails, and pallor. The other options are not commonly associated with iron deficiency.

Clinical Pearls

All areas with asterisks are highlighted for a patient with this chief complaint.

Iron deficiency anemia

  • In post-menopausal women and men always suspect GI blood loss as the cause of anemia until proven otherwise
  • Consider malabsorption and dietary intake

Ask:

  • Fatigue, weakness, pallor, dyspnea of exertion, pica, brittle nails, angular cheilitis, glossitis, restless legs

Physical exam:

  • Pale conjunctiva, koilonychia, smooth red tongue, tachycardia, murmur

Diagnostics:

  • Classic laboratory value pattern:
    • Hemoglobin ↓
    • Mean corpuscular volume (MCV) ↓
    • Ferritin ↓
    • Serum iron ↓
    • TIBC ↑
    • Transferrin saturation ↓

Treatment:

  • Investigate cause and mitigate (if possible)
  • Iron repletion and/or blood transfusion if severe
  • Best taken on an empty stomach with vitamin C
  • Educate patients on side effects of oral iron (nausea, constipation, dark stool)

References

Auerbach, M., & DeLoughery, T. G. (2025). Diagnosis of iron deficiency and iron deficiency anemia in adults. In R. T. Means (Ed.), UpToDate. https://www.uptodate.com/contents/diagnosis-of-iron-deficiency-and-iron-deficiency-anemia-in-adults

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Be Prepared for Your Nurse Practitioner Clinical Readiness Exam Copyright © 2026 by Elizabeth Heavey, Renee Biedlingmaier, Colleen Burgoyne and Carnel C. Jackson is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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