Materials relevant to this exercise may have been distributed by students or posted in prior years.

Such materials
are not a legitimate source for studying or completing this assignment. Use of them should be considered prohibited
under the Student Honor Code.

2010 BLOOD SYSTEM COURSE: RED CELL ASSIGNMENT

You may work on homeworks in any way you wish, including in groups. Your answers MUST be
in your own words, however, and should be submitted as a PC-compatible file for grading via
ePortfolio. DEADLINE: Tuesday October 5th at midnight. Be sure to give the file you post your
name and an indicator it is homework 1 (red cells). Only use email to send it if there’s a
problem with ePortfolio you tell me or I tell you about. IMPORTANT: Please detach the
picture before posting or sending. I take good care but am not responsible for files not sent or
labeled as described. The assignment carries 6% of the course grade. Be succinct. There will be
significant credit for complete, accurate, well written answers which take up only a page or so.

Case presentation and history

RG is a 71-year-old woman, a native of the former Soviet Union, who has
lived for a number of years with her daughter, a Stony Brook University
faculty member. RG was referred to the hematology service by Memorial
Sloan Kettering Cancer Center and admitted here at Stony Brook January 15th
with the chief complaints of extreme weakness, tingling in her extremities,
dizziness, fatigue, and the feeling that her heart is pounding in her chest.
With her daughter helping, Mrs. G. explains she has recently been unable to
complete a day at home without taking 3 or 4 hour–long naps; this has been
going on for several weeks. It is almost impossible for her to get up and
down stairs, and so (with her daughter teaching at the University all day) she
often just stays in bed. Mrs. G was previously in reasonably good health
except that, earlier in January, she was seen at Memorial Sloan Kettering for
evaluation of a thyroid mass first diagnosed in the USSR as a "low grade"
malignancy in 1978, and treated non-surgically over the intervening years
(though only sporadically) with either Synthroid® or generic levothyroxine.

Extending the evaluation begun at Memorial Hospital, we find the following:

Selected physical findings
On physical exam Mrs. G. is a pale, somewhat lethargic woman in no acute
distress, who appears her stated age.
o Blood pressure right arm seated, 130/80 mm Hg.
o Pulse 88 per minute, regular.
o Respirations normal. Patient is afebrile.
o One possible enlarged supraclavicular lymph node palpated, otherwise
no lymphadenopathy.
o Conjunctiva are pale, sclera anicteric.
o Lungs clear, cardiac exam unremarkable, abdomen soft non–tender, no
organomegaly.
o There is fullness and induration over the left lobe of the thyroid.

Relevant laboratory values

Memorial= Stony Brook
Normal range
§
January 7th †
January 22nd

†
Two units packed red cells were transfused at Memorial and two units again at UHMC on Jan.
15th.
§
The hemogram was essentially identical at UHMC January 15th when iron (Feosol®) 3 times
daily was prescribed.
Materials relevant to this exercise may have been distributed by students or posted in prior years. Such materials
are not a legitimate source for studying or completing this assignment. Use of them should be considered prohibited
under the Student Honor Code.
Hemoglobin 6.0 g/dL 9.6 g.dL 12.0 –
16.0
Hematocrit 22.0 vol % 26.9 vol % 37.0 – 47.0
Mean corpuscular volume 65 fL 69.2 fL 80.0 –
97.0
MCH 22.3 pg 27.0 –
31.0
MCHC 32.2 g/dL 32.2 – 37.0
Red cell distribution width (RDW) 28.2% 11.2 –
14.8
Serum iron 21 µ g/dL 30 – 160
Plasma ferritin 2 ng/ml
10–291
Serum folate 12.8 ng/mL 2.9–13.5
Serum vitamin B12 334 pg/mL 199–732
White blood cells 7,500/µ l, normal
differential
Stool guaiac Negative
Barium enema, GI and small bowel series Negative in all
respects
Melena, hematemesis, vaginal bleeding None
reported

The blood smear of January 22nd is shown below, approx ¼ of a high-power

field. In addition to what’s in this view it displayed a few tear drop cells,
schistocytes, burr cells, and rouleaux.

Questions (one point each)

1. a) What is the diagnosis? [Confine this first answer to a general,
broad definition.]
b) What is the most likely explanation for her disorder? Upon what
pieces of information do you base this conclusion? [Now, be more
specific, selecting findings from the labs above.]
Materials relevant to this exercise may have been distributed by students or posted in prior years. Such materials
are not a legitimate source for studying or completing this assignment. Use of them should be considered prohibited
under the Student Honor Code.

2. In view of the history, what other explanation for her symptoms might
be considered? Pick one answer (there are several possibilities to
choose from, not necessarily hematologic in nature) and explain its
possible contribution.
3. How would the alternative diagnosis in question 2 have affected the
patient’s red blood cells and/or bone marrow (be specific for your
particular choice)?
4. What single piece of information helps you eliminate answers 2 and 3?
5. Briefly define the RDW and what it’s used for. Why was the RDW so
high on January 22nd? Connect that piece of data to the appearance of
the blood smear, above.
6. Speculate on a mechanism for Mrs G’s underlying disease.