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A 64-year-old man is evaluated for mild worsening dyspnea

and a minimal gradual decrease in exercise tolerance over the
past 2 weeks associated with his chronic obstructive
pulmonary disease. He had an acute coronary syndrome 2
years ago, and his medications include daily aspirin, inh.
ipratropium, inh. corticosteroids, metoprolol, and atorvastatin.
On physical examination, pulse rate is 98/min, respiration rate
is 20/min, and blood pressure is 130/90 mm Hg. Laboratory
studies include a hemoglobin of 9.6 g/dL and mean
corpuscular volume of 78 fL. Stool is positive for occult
blood. Iron-deficiency anemia is diagnosed. Upper endoscopy
reveals chronic gastritis, and the daily aspirin is stopped.

Which of the following is the most

appropriate treatment for this patient's

A Blood transfusion
B Intravenous iron
C Oral iron
D Erythropoietin



A 62-year-old man is evaluated during a routine

examination. His history is significant for colon
cancer that was successfully treated with resection
12 years ago. He has no fatigue or other medical
complaints, and the remainder of the history is
On physical examination, there are symmetrical
swelling and effusions noted, consistent with
rheumatoid arthritis in the metacarpophalangeal
and proximal interphalangeal joints bilaterally.

Laboratory Studies:
Hemoglobin 10.1 g/dL; WBC 6200/L; Mean
corpuscular volume 90 fL
Platelet count 234,000/L
Reticulocyte count 0.1% of erythrocytes
Serum ferritin 250 ng/mL; Serum iron 37 g/dL;
Serum total iron-binding capacity 175 g/dL
The peripheral blood smear is normal

Which of the following is the most

appropriate next step in management
of the anemia?

A Packed red blood cell transfusion

B Oral ferrous sulfate
C Erythropoietin
D No treatment necessary



A 69-year-old man is evaluated for fatigue. He has a history of aortic stenosis and
underwent aortic valve replacement with a mechanical prosthesis 6 months ago. He did
well during his postoperative course, returning to his normal preoperative level of
activity within 2 to 3 months. However, over the past 3 weeks, he has noted mild,
progressive exertional dyspnea while walking uphill during his daily walks. He reports
no fevers, chills, weight loss, dental procedures, or sick contacts. His medications
include warfarin and an antihypertensive medication.
He is afebrile, with a heart rate of 86/min and blood pressure of 134/82 mm Hg. His
cardiac examination reveals a mechanical S2 and a normal S1 without S3 or S4. There is
a nonradiating, mid-peaking grade 2/6 systolic ejection murmur heard at the upper left
sternal border. The rest of his physical examination is unremarkable.
Pertinent laboratory results include a hematocrit of 29% and an MCV of 76, a normal
leukocyte and platelet count, and an INR of 2.6. The basic metabolic panel is normal.
Serum lactate dehydrogenase and haptoglobin levels are normal. The blood smear shows
hypochromic, microcytic erythrocytes. Transthoracic echocardiogram demonstrates a
normally functioning aortic prosthesis without regurgitation and is otherwise

Which of the following tests should

be obtained next?

A Colonoscopy
B Transesophageal echocardiography
C Bleeding time
D Fluoroscopy of the mechanical prosthesis
E Stool testing for occult blood



A 24-year-old woman is evaluated during a routine

exam. The medical history and physical
examination are noncontributory.
Laboratory studies include a hemoglobin of 11.5
g/dL, a mean corpuscular volume of 60 fL, and a
red blood cell count of 5.5 million cells/L. The
leukocyte and platelet counts and results of
hemoglobin electrophoresis are normal. The
peripheral blood smear is shown:

Which of the following is the most likely

composition of her gene alleles?
A (, ) /(, )
B (,) /(,)
C (,) /(,)
D (,) /(,)
E (b) / (-)



A 52-year-old man is evaluated for the recent finding of

anemia on a routine blood workup. He has a history of
hypertension treated with a thiazide diuretic. The
remainder of the medical history and physical examination
are normal.
Laboratory Studies:Hemoglobin 11.8 g/dL. Leukocyte
count 6400/L with a normal differential. Mean
corpuscular volume 84 fL. Platelet count 400,000/L.
Serum creatinine 0.8 mg/dL. Serum ferritin 760 ng/mL.
Serum iron 45 g/dL. Serum total iron-binding capacity
180 g/dL. The peripheral blood smear is normal.

Which of the following is the most

appropriate management for this patient?

A start oral iron sulfate

B stop thiazide diuretic
C check Hb electrophoresis
D None of the above



A 67-year-old woman is evaluated for increasing

forgetfulness. The problem has been slowly
progressive over the past few months. She is able
to live independently and has not had difficulty
performing the usual activities of daily living. She
has no other medical problems and takes no
medications. The remainder of the medical history
and physical examination are noncontributory

Laboratory Studies
Hemoglobin 7.8 g/dL
Leukocyte count 2,300/L
Mean corpuscular volume 110 fL
Platelet count 118,000/L
Serum lactate dehydrogenase 565 U/L
Serum direct bilirubin 0.3 mg/dL
Serum total bilirubin 4.8 mg/dL
Serum vitamin B12 level is 325 pg/mL (normal is > 300)
Serum folate 12 ng/mL

Which of the following is the most

likely cause of the patients symptoms?

A Aplastic anemia
B Vitamin B12 deficiency
C Autoimmune hemolytic anemia
D Acute leukemia
E Folate deficiency

Which of the following tests will be


A Ferritin
B Methylmalonic acid
D Coombs test



A 36-year-old woman is evaluated in the emergency department for severe

fatigue that has worsened over the past 3 months and recurrent epistaxis that
has occurred over the past week.
She has not had fever or a recent illness, nor does she have any risk factors for
HIV infection.She has not taken any over-the-counter medications nor used
alcohol. On physical examination, petechiae are noted in the buccal mucosa
and lower extremities. There is no lymphadenopathy or splenomegaly.
Laboratory studies on hospital admission indicate a normal activated partial
thromboplastin time and prothrombin time, a hematocrit of 23%, leukocyte
count of 1200/L, neutrophil count of 300/L, platelet count of 15,000/L,
and a reticulocyte count of 0.2% of erythrocytes. Serum chemistries, including
lactate dehydrogenase, are normal. No significant red blood cell abnormalities
are noted on peripheral blood smear. Chest radiograph is unremarkable. The
bone marrow biopsy is shown.
The patient receives a transfusion with packed red blood cells and platelets.



A 64-year-old man is evaluated during a routine

examination. Medical history is significant for
osteoarthritis, for which he takes aspirin and
On physical examination, pallor is absent. Blood
pressure is 116/72 mm Hg, with no orthostatic
changes, and pulse rate is 68/min. The remainder
of the examination is normal.

Laboratory studies:
Hemoglobin 9.7 g/dL
Leukocyte count 5800/L
Platelet count 265,000/L
Mean corpuscular volume72 fL
Reticulocyte count 0.5% of erythrocytes
Lactate dehydrogenase 80 U/L
Iron 40 g/dL
Total iron-binding capacity 200 g/dL
Ferritin 210 ng/mL
Results of the peripheral blood smear are normal

Which of the following is the most

likely diagnosis?

A Inflammatory anemia
B Hemoglobin C disease
C Iron deficiency
D Thalassemia



A 62-year-old man undergoes a routine

examination. The patient has a severe iron
deficiency of many years duration as well as
hypertension. He also underwent a proximal small
bowel resection 7 years ago necessitated by a gun
shot injury. Current medications are ferrous
sulfate, 325 mg/d, and atenolol, 50 mg/d.
On physical examination, he has pale
conjunctivae. Temperature is 98.0 F, blood
pressure is 136/75 mm Hg, pulse rate is 62/min,
and respiration rate is 14/min

Laboratory studies:
Hemoglobin7.3 g/dL (73 g/L)
Mean corpuscular volume58 fL
Reticulocyte count 0.2% of erythrocytes
Iron 13 g/dL (2.3 mol/L)
Total iron-binding capacity427 g/dL (76.4
Ferritin1 ng/mL

Which of the following is the most

appropriate management?
A Add ascorbic acid to ferrous sulfate
B Increase oral ferrous sulfate dosage to
650 mg/d
C Switch to another oral iron type
D Switch to intravenous iron