question: Q:A 71-year-old man comes to the physician for routine health maintenance examination. He feels well. He has hypertension and gastroesophageal reflux disease. Current medications include metoprolol and pantoprazole. He does not smoke or drink alcohol. Temperature is 37.3°C (99.1°F), pulse is 75/min, and blood pressure 135/87 mm Hg. Examination shows no abnormalities. Laboratory studies show:
  Hematocrit 43%
  Leukocyte count 32,000/mm3
  Segmented neutrophils 22%
  Basophils 1%
  Eosinophils 2%
  Lymphocytes 74%
  Monocytes 1%
  Platelet count 190,000/mm3
  Blood smear shows small, mature lymphocytes and several smudge cells. Immunophenotypic analysis with flow cytometry shows B-cells that express CD19, CD20 and CD23. Which of the following is the most appropriate next step in management?"? 
  {'A': 'Stem cell transplantation', 'B': 'All-trans retinoic acid', 'C': 'Observation and follow-up', 'D': 'Fludarabine, cyclophosphamide, and rituximab', 'E': 'Imatinib'},