Question

Case Study : A 70-yr-old male, who had been getting progressively more tired and lethargic the past few months, sought medical advice. The patient appeared thin with noticeable pallor of the nail beds and mucus membranes. A CBC revealed his hemoglobin to be 9.1 g/dL and his hematocrit was 30.0%. He was placed on iron supplementation and told to return for follow-up blood work in six weeks. Six weeks later his hematocrit had dropped to 25.7% (see CBC below). CBC WBC (x 109/L) 4.0N RBC (x 1012/L) 2.10L HGB (g/dl) 8.5L HCT (%) 25.7L RBC INDICES MCV (fl) 122H MCH (pg) 40H MCHC (g/dl) 33N RDW (%) 21H PLT (x 109/L) 120L RETIC COUNT (%) 0.7N

DIFFERENTIAL

            WBC identification             Relative (%)             Absolute (x10⁹/L)                     

                        segs                             40                                1.6

                        lymphs                         49                                2.0

                        monos                            8                                0.3

                        eos                                  3                                0.1

                        basos                           0                                0.0

1. Are his CBC and differential results within the normal range? If not, indicate those

that are outside the reference range.

2. How would you categorize his red cells morphologically (i.e. normo-, macro-or

microcytic; hypo- or normochromic)?

3. In what conditions would you see similar CBC results? Be specific.

Based on the clinical history and CBC results above, chemistry testing was performed and the following results obtained:

                        Sodium =          140 mmol/L

                        Potassium =      4.6 mmolL

                        Chloride =         99 mmol/L

                        Bicarbonate =   26 mmol/L

                        AST =               30 U/L

                        ALT =               38 U/L

                        Glucose =         92 mg/dL

                        Total bilirubin = 0.9 mg/dL

                        Serum iron=      82 ug/dL

                        Serum ferritin = 70 ug/L

                        B₁₂ =                 312 pg/ml

                        Folate =            2.0 ng/ml    (serum level– radioassay)

            4. Are his chemistry results within the normal range? If not, indicate those that are outside the

    reference range.

5. What information do the ALT and AST results provide concerning this patient?

            6. What disorder is suggested by the clinical history and test results on this patient? Justify

     your answer.

            7. Bone marrow

(a) Describe the characteristic appearance of the bone marrow in this disorder.

(b) Discuss the mechanism responsible for these characteristic bone marrow findings.

            8. (a) Calculate the absolute reticulocyte count - show all your work. Is it normal or abnormal?

                (b) Based on your diagnosis, is this the result you would have expected?

           

            9. Schilling Test

                 Review the results of the Schilling test below and suggest the most likely diagnosis based on

                 these findings. Explain your answer.

-Part I, before intrinsic factor = 6.0%

                                    -Part II, after intrinsic factor = 8.0%

            10. Why do you think his hematocrit continued to drop after iron supplementation?

                       

Answer 1

Abnormal CBC and WBC values:

RBC count is less than normal. normal range is 4.2-5.9*1012/L

WBC count is less than normal; normal range is 4.3-10.8*109/L

Platelet count is less than normal ; normal range is150 - 400 x 10⁹ per liter

MCV (mean cell volume) is high . normal range is 76-96 fL

RDW (Red cell distribution width) is high ;normal range is 8.6-13.6%

Lymphocytes are more than normal ;normal range is 20-40%

Macrocytic -size of red blood cells are large than normal.

CBC reports shows pancytopenia( low RBC WBC and platelet count).

pancytopenia seen in conditions like aplastic anemia acute myeloid leukemia , lymphomas .

4) chemistry results are within normal range.

this patient has normal AST and ALT levels that indicates that he has no liver disease and is not responsible for the cause of his macrocytic anemia .

6) Based on the clinical history and CBC results, he has megaloblastic or macrocytic anemia. he also has pancytopenia which is most common cause of .megaloblastic or macrocytic anemia.this is caused by deficiency or impaired absorption of B12 from the gut.