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DTP Assignment Case # 3Hematology TEAM-Together we achieve moreStephanie Shaw: History, PE, HxQs Editor/NarratorRuchita Uxa: Pathophysiology, Lab Investigations & interpretationNusrat Parveen: DDx, Dx & managementMaryam Pazoki: Prognosis and Patient education16th JUNE 2014

1Hematology Case 3OverviewHistoryPhysical ExaminationLab Investigations: results and interpretationAssessment: DDx and most likely DxManagementPrognosis and Patient education

2History37 year old male.Seizure disorder since age 2.During his routine neurology check:he has complained of feeling fatigued, shortness of breath on exertion, lightheadedness over the past month or so.

3Additional Relevant History QuestionsDietary history, including alcohol intake (Vegan, GI complications)Past medical history, including recent surgeries/hospitalization, blood transfusions or blood products Family history, including place of origin and possible hereditary medical conditions (Thalassemia, genetic predisposition)Medications that you are currently taking for seizure disorder or any other condition (Rx and/or OTC) PhenytoinExperience of weight gain, constipation, muscle aches, or feeling unusually cold? (Signs and symptoms of Hypothyroidism, possible cause of Anemia) Change or absence in sense of touch and feeling? (paresthesia)Any recent fevers, or infection? (anemia of chronic disease)

4Physical ExamSkin pallor noted. Otherwise, physical exam was unremarkable.

5Laboratory InvestigationsRBC 1.24 x 1012/L Hgb 58 g/L Hct 0.162 MCV 131 fL MCHC 348 g/L RDW 0.184 WBC 6.1 x 109/L Neutrophils 73 % Lymphocytes 21% Monocytes 1% Eosinophils 4% Basophils 1% Platelets 219 x 109/Lblood smear analysisRed blood cellsNormochromic2+ macrocytosis2+ anisocytosismany oval macrocytesOccasional teardrop cells and fragments

WBC morphologyMultiple neutrophils with nuclear hypersegmentation

Platelets normal

6Laboratory InvestigationsBone marrow biopsy:Numerous Howell Jolly bodies. Increased number of erythroids with megaloblastic maturation. Neutrophils show premature nuclear segmentation. Giant metamyelocytes and band forms.

Chemistry:Serum folate