What are the essential questions to ask and evaluations to perform during the initial consultation for a middle-aged male with newly diagnosed iron deficiency anemia?

Essential Questions for Initial Consultation: Middle-Aged Male with New Iron Deficiency Anemia

Dietary and Medication History

Take a detailed dietary history to identify inadequate iron intake, though borderline iron-deficient diets are common and should not be presumed as the sole cause—full GI investigation remains necessary even with positive dietary findings. 1

• Document all NSAID and aspirin use (including over-the-counter medications), as these are common causes of IDA and should be stopped when clinically feasible 1
• Ask about anticoagulant use (warfarin, DOACs, etc.) 1
• Inquire about proton pump inhibitor use, which can impair iron absorption 1
• Ask about blood donation history 1

Gastrointestinal Symptoms and Blood Loss

• Ask about both upper and lower GI symptoms, though these rarely correlate with investigation findings and their absence should not deter investigation 1
• Document any history of visible blood loss (melena, hematochezia, hematemesis) 1
• Ask about chronic nosebleeds 1
• Inquire about previous GI surgery (gastrectomy, gastric bypass, bowel resection), as these significantly impair iron absorption 1

Family History

• Screen for family history of GI malignancy (especially colorectal cancer), as this lowers the threshold for investigation 1
• Ask about hereditary hemorrhagic telangiectasia (family history of nosebleeds, telangiectasias) 1
• Document family history of hematological disorders (thalassemia, sideroblastic anemia) that could mimic or complicate iron deficiency 1
• Ask about family history of celiac disease 1

Symptoms of Iron Deficiency and Anemia

• Assess for specific iron deficiency symptoms beyond anemia: restless legs syndrome (present in 32-40% of iron-deficient patients), pica or pagophagia (ice craving, present in 40-50%), angular stomatitis, glossitis, koilonychia (spoon nails), blue sclerae 1, 2
• Document symptoms of anemia: fatigue, breathlessness, exercise intolerance, lightheadedness, difficulty concentrating, irritability, depression 1, 2
• Ask about worsening of any underlying heart failure 2

Non-GI Causes to Exclude

• Inquire about urinary symptoms (hematuria), as urinalysis or urine microscopy should be part of initial investigation 1
• Ask about chronic inflammatory conditions (inflammatory bowel disease, chronic kidney disease, heart failure, cancer, rheumatologic conditions), as these can cause functional iron deficiency with elevated ferritin 1, 2
• Document recent pregnancy or surgical history 1

Risk Stratification for Malignancy

In middle-aged men with IDA, the risk of GI malignancy is substantial—age, sex, hemoglobin concentration, and mean cell volume are all independent predictors of GI cancer risk. 1

• Document exact hemoglobin level, as men with Hb <12 g/dL should be investigated more urgently due to higher likelihood of serious disease 1
• Note that in men and postmenopausal women, approximately one-third have underlying pathological abnormalities, most commonly in the GI tract 1

Physical Examination Findings to Document

• Perform digital rectal examination 1
• Look for signs of hereditary hemorrhagic telangiectasia (mucosal telangiectasias) 1
• Document any signs of chronic liver disease or portal hypertension 1
• Check for lymphadenopathy or organomegaly 1

Key Pitfall to Avoid

Do not accept a positive dietary history or NSAID use as the sole explanation for IDA in a middle-aged male—bidirectional endoscopy (gastroscopy and colonoscopy) should generally be first-line GI investigation regardless, as dual pathology occurs in 10-15% of patients. 1