Question

Mrs. Williams is a 45-year-old Caucasian woman who sought medical attention for fatigue that developed during the previous month. She reported no chest pain, but did feel mildly short of breath with exertion such as after walking up a flight of stairs. She denied any rectal bleeding, but she had heavy menstrual periods for about a year. Her past medical history included being treated for anemia following her third pregnancy 10 years earlier. She was not taking any prescribed medications. Her family history revealed that her parents were born in Italy and died when she was in grade school. She did not know their medical history.

A physical examination revealed that Mrs. Williams’s general appearance was pale but with no acute distress.

Her vital signs were blood pressure 125/90 mm Hg, heart rate 118 beats/min regular, and respirations 26 breaths/min. No significant changes in the blood pressure and heart rate were noted between the supine and upright positions. Other findings included pale conjunctiva and moist mucous membranes without lesions. No adenopathy or hepatosplenomegaly was noted.

Breath sounds were clear to auscultation, and the heart had a regular rate and rhythm with a murmur. The abdomen was soft, nontender, and nondistended.

A rectal examination revealed no masses, and heme-negative brown stool was present. Additionally, Mrs. Williams reported that she was taking aspirin 81 mg daily, she is a vegetarian who eats a lot of cereal, and she did not have an urge to eat ice. Mrs. Williams’s laboratory tests revealed the following results:

CBC	Result	Normal Range
WBC	8.2 × 103/mL	4.8–10.8 × 103/mL
Hgb	8.0 g/dL	12–15.6 g/dL
Hct	24%	35–46%
RBC	4.0 × 106/mL	3.8–5 × 106/mL
MCV	60 μL/red cell	80–96.1 μL/red cell
MCH	20 pg/red cell	27.5–33.2 pg/red cell
MCHC	33 g/L	33.4–35.5 g/L
RDW	16.5	11.5–14.5
platelets	500,000/mL	150–400,000/mL
reticulocyte count	3%	0.5–1.7%
absolute reticulocyte count	40,000/mL	25,000–75,000/mL
LDH	210 U/L	0–304 U/L

CBC = complete blood count; WBC = white blood cells; Hgb = hemoglobin; Hct = hematocrit; RBC = red blood cells; MCV = mean corpuscular volume; MCH = mean corpuscular hemoglobin; MCHC = mean corpuscular hemoglobin concentration; RDW = red cell distribution width;
LDH = lactate dehydrogenase.

1. Which type of hematologic disorder would you suspect based on Mrs. Williams’s history, physical examination, and laboratory values?
   1. Infectious mononucleosis
   2. Iron-deficiency anemia
   3. Pernicious anemia
   4. Thalassemia
2. Which of Mrs. Williams clinical signs are reflective of the body’s effort to compensate for her red blood cells’ decreased oxygen-carrying capacity?
   1. Heart rate 118 beats/min and respiration rate 26 breaths/min
   2. Hematocrit 24% and hemoglobin 8 g/Dl
   3. Blood pressure 125/90
   4. Persistent fatigue

Mrs. Williams was placed on iron supplements. Her hemoglobin (Hgb) was expected to be normal after approximately 8 weeks of iron therapy, which was anticipated to raise the Hgb about 1 g/dL per week. However, her Hgb was 9.5 g/dL after 8 weeks.

Following those results, Mrs. Williams was asked whether she had been taking the iron supplements as ordered and whether she had been tolerating the medication. Additionally, she was asked whether she was having dark, tarry stools, which would indicate gastrointestinal bleeding.

Mrs. Williams reported that she had taken the iron supplement for only 2 weeks because it made her nauseated and constipated. Mrs. Williams was instructed to take the iron supplement with a light carbohydrate such as crackers or toast to minimize the nausea and to take measures to prevent constipation (e.g., increasing fiber and water intake). After implementing these measures and taking the iron supplement as ordered for 8 weeks, Mrs. Williams’s Hgb returned to normal.

3. In addition to iron supplements, which kinds of food would be recommended for Mrs. Williams to consume?
   1. Milk, cheese, soybeans, broccoli, and almonds
   2. Green leafy vegetables and avocados
   3. Orange juice, raisins, bananas, cantaloupe, and fish
   4. Liver, red meat, eggs, dark green leafy vegetables, nuts, and legumes

Answer 1