question: Q:A 59-year-old man presents to his primary care physician for fatigue. In general, he has been in good health; however, he recently has experienced some weight loss, abdominal pain, and general fatigue. He has a past medical history of anxiety, diabetes, a fracture of his foot sustained when he tripped, and a recent cold that caused him to miss work for a week. His current medications include metformin, insulin, buspirone, vitamin D, calcium, and sodium docusate. His temperature is 99.5°F (37.5°C), blood pressure is 150/100 mmHg, pulse is 90/min, respirations are 18/min, and oxygen saturation is 98% on room air. Physical exam reveals a calm gentleman. A mild systolic murmur is heard in the left upper sternal region. The rest of the physical exam is within normal limits. Laboratory values are ordered as seen below.
  
  Hemoglobin: 12 g/dL
  Hematocrit: 36%
  Leukocyte count: 66,500/mm^3 with normal differential
  Platelet count: 177,000/mm^3
  Leukocyte alkaline phosphatase: elevated
  
  Serum:
  Na+: 139 mEq/L
  Cl-: 100 mEq/L
  K+: 4.3 mEq/L
  BUN: 20 mg/dL
  Glucose: 120 mg/dL
  Creatinine: 1.1 mg/dL
  Ca2+: 10.9 mEq/L
  AST: 12 U/L
  ALT: 10 U/L
  
  Which of the following is the most likely diagnosis?? 
  {'A': 'Acute lymphoblastic lymphoma', 'B': 'Chronic lymphocytic leukemia', 'C': 'Chronic myeloid leukemia', 'D': 'Leukemoid reaction', 'E': 'Multiple myeloma'},