A 51 yo woman is being evaluated for anemia.  She has a long history of anemia dating back to high school.  She was given red cell transfusions on two previous occasions, following the birth of her daughter 30 years ago and again following open heart surgery 4 months ago.  She had been prescribed oral iron pills in the past but was unable to tolerate these because of GI side effects

Past history:


Family history: Her mother had anemia of uncertain cause. No other family history of hematologic disease.  Both parents had coronary artery disease.

Social History: Married, one daughter. Never smoked.  Consumes alcohol rarely.

Review of systems:  Has felt severely fatigued following heart surgery, with some improvement after red cell transfusion.  Recent weight gain attributed to fluid retention caused by heart problems, treated with diuretics. No fever, chills. Had been amenorrheic since receiving chemotherapy for lymphoma, but had an episode of vaginal bleeding following heart surgery.  Scheduled to see a gynecologist for further evaluation.  Has noted occasional dark or black stools.

Physical examination: BP 99/64, pulse 93, temp 36.7, resp 18.  Not icteric, no oral lesions.  Jugular venous pressure appears increased.  Metallic S1/S2, regular rhythm. Scattered lung wheezes. Abdomen obese with surgical scar in left upper quadrant. 1+ pitting edema of ankles. 

Select tests that you think might be helpful from the test menu below.

  1. How many different potential causes for anemia can you identify in this case?
  2. Which do you think is the most important, and why?


Blood Bank
ABO & Rh Typing ($46.40)
Antibody Screen ($89.10)
Direct Coombs

Body Fluids
Stool Occult Blood

Basic Chem ($174)
Bilirubin ($42)



Prothrombin time/INR ($33)

CBC and differential ($65)
Reticulocyte count ($33.45)
Blood smear ($28.75)
Iron studies ($231.20)
Folate & B-12 ($249.00)
Haptoglobin ($106.00)
Hemoglobin electrophoresis ($199.35)
Serum erythropoietin level

Other tests
Chest X-ray ($220)
Upper GI Endoscopy ($3649.00)
Colonoscopy ($4557.00)
Bone marrow aspirate & biopsy ($3679.00)