Question m36

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

anemia?

• A Blood transfusion

• B Intravenous iron

• C Oral iron

• D Erythropoietin

Question m23

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 noncontributory. 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/μL; Mean

corpuscular volume 90 fL• Platelet count 234,000/μL• Reticulocyte count 0.1% of erythrocytes• Serum ferritin 250 ng/mL; Serum iron 37 μg/dL;

Serum total iron-binding capacity 175 μg/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

Question m59

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 unremarkable.

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

Question m13

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/μL. 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 (α, α) /(α, α)

• B (α,––) /(α,––)

• C (––,––) /(––,α)

• D (––,––) /(––,––)

• E (b) / (-)

Question m45

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/μL with a normal differential. Mean corpuscular volume 84 fL. Platelet count 400,000/μL. Serum creatinine 0.8 mg/dL. Serum ferritin 760 ng/mL. Serum iron 45 μg/dL. Serum total iron-binding capacity 180 μg/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

Question m50

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/μL• Mean corpuscular volume 110 fL• Platelet count 118,000/μL • 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 abnormal?

• A Ferritin

• B Methylmalonic acid

• C TIBC

• D Coomb’s test

Question m22

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/μL, neutrophil count of 300/μL, platelet count of 15,000/μL, 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.

Question m10

A 64-year-old man is evaluated during a routine examination. Medical history is significant for osteoarthritis, for which he takes aspirin and acetaminophen.

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/µL • Platelet count 265,000/µL • Mean corpuscular volume72 fL• Reticulocyte count 0.5% of erythrocytes • Lactate dehydrogenase 80 U/L • Iron 40 µg/dL• Total iron-binding capacity 200 µg/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

Question m17

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 µg/dL (2.3 µmol/L)• Total iron-binding capacity427 µg/dL (76.4

µmol/L)• Ferritin1 ng/mL

Which of the following is the most appropriate management?

• A Add ascorbic acid to ferrous sulfate therapy

• B Increase oral ferrous sulfate dosage to 650 mg/d

• C Switch to another oral iron type

• D Switch to intravenous iron