A 60-year-old female presents to your primary care office complaining of worsening fatigue over the last 3-4 months, and now over the previous 2 weeks, complains of occasional dyspnea on exertion. She denies any chest pain or lower extremity swelling. During this period of time, she has noticed an increased urge for eating ice chips. The remainder of her review of systems is negative. Vitals signs recorded today show a blood pressure of 106/72 mmHg, a heart rate of 106, a respiratory rate of 18, and oxygen saturation of 98% on room air. Physical examination is significant for pale conjunctiva, angular chelitis, and a new I/VI systolic murmur at the left lower sternal border, no S3 or rub noted. Lungs were clear to auscultation bilaterally.

Laboratory evaluation of the patient shows the following:


WBC – 5,500 with normal differential

RBC – 5.0

Hgb – 6.2

Hct – 19%

Platelets – 242,000

MCV – 62

MCH – 24

RDW – 19%


  1. How would you define this patient’s anemia using the RBC indices in the lab work above?  (10 points)
  2. List at least 5 potential etiologies of this patient’s diagnosis. (10 points)
  3. What is the differential diagnosis for these lab findings? Which of these is your most likely diagnosis for this patient? (10 points)
  4. What additional laboratory evaluations would you want to order for this patient? What would be your expected findings for these lab studies? (10 points)
  5. Explain the pathophysiology of reticulocyte production as it relates to anemia.  For example, explain what it means if the patient has a normal or low reticulocyte count versus an elevated reticulocyte count. (10 points)
  6. Explain differences in the roles of ferritin and transferrin (TIBC).  Explain what ferritin and transferrin do and how they react when there is an excess of iron in the blood.  (10 points)
  7. Explain the pathophysiology of what happens to TIBC and ferritin in a patient with iron deficiency anemia. (10 points)
  8. Explain the pathophysiology of what happens to TIBC and ferritin in a patient with anemia of chronic disease. (10 points)
  9. Explain what lab indices would appear to like in a patient with macrocytic anemia.  (10 points).
  10. Explain the Schilling test. (10 pts)

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