WEEK 3 Case Study A 70-yr-old male, who had been getting progressively more tire
ID: 230465 • Letter: W
Question
WEEK 3 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 H&H to be 9.1 g/dL and 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) 4.0
RBC (x 1012/L) 2.10
HGB (g/dl) 8.5
HCT (%) 25.7
RBC INDICES
MCV (fl) 122
MCH (pg) 40
MCHC (g/dl) 33
RDW (%) 21
PLT (x 109/L) 120
RETIC COUNT (%) 0.7
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
RBC morphology Moderate poikilocytosis, moderate anisocytosis, several ovalocytes,
occasional Howell-Jolly bodies, neutrophils with 6 lobes noted.
Platelet estimate 7 / OIF
QUESTIONS
Are his CBC and differential results within the normal range? If not, indicate those
that are outside the reference range.
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?
Explanation / Answer
CBC and Differential results are not within the normal range. Normal range is given at right hand side.
1) RBC (x 1012/L) Low 2.10 Normal ( 3.5 -55)
2) HGB (g/dl) Low 8.5 Normal ( 12 - 16)
3) HCT (%) Low 25.7 Normal (38 -50 )
4) RDW (%) High 21 Normal ( 11-14.5)
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