CPC #1: Tuesday, September 25, 2001
Hurd Hall, The Johns Hopkins Hospital
12 Noon

An 81 year old male with new onset pancytopenia on a routine annual exam.

HPI: This previously healthy 81 year-old male had a normal annual physical examination.  However, his CBC showed WBC 1700 /cu mm (normal range, 4,500-11,000) with 22% neutrophils (normal range, 40-70%) and occasional “atypical”cells, hematocrit 33% (normal range, 41-53), and platelet count 43,000 /cu mm (normal range, 150,000-350,000). He therefore was referred to a hematologist.  He is essentially without symptoms, toxin or new drug exposure. His occupational history is perhaps relevant in that he is a pediatrician who worked primarily in research, had experience using fluoroscopic equipment to examine patients, and worked with isotopes 40 or more years ago at the Brookhaven National Laboratories.  Of note, a CBC drawn 2 years ago was completely normal.

Review of Systems: He is currently without fevers, sweats, or significant weight changes. There is no loss of vision, double vision, headaches, mouth ulcers, or dysphagia. He denies chest pain or pressure, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, cough, or mucous production. He denies abdominal pain, constipation, diarrhea, blood in stool, or tarry stool. He denies dysuria, frequency, hesitancy, extremity weakness, tingling or tremor.

PMH: An episode of hay-fever in 09/2000 from which he recovered. Left inguinal hernia not surgically repaired. He is being followed for a questionable nodule on his prostate.

Past Surgical History: Left hip replacement (1997) and appendectomy.

Social history: He is a pediatrician who spent his life’s work in research. He drinks 2-3 ounces of alcohol per day and denies tobacco use.

Family history: His mother died of an AMI. His father, who was a smoker, died of a stroke. He has two sisters who are alive and well. He has two brothers, one of whom has ataxia of unknown cause and one of whom is “slow”. He has six children who are alive and well.

Allergies: NKDA

Medications: Glucosamine and chondroitin sulfate.

PE: The patient is well-developed, well-nourished male in no acute distress. Oral examination demonstrates no mucositis or ulceration. Lungs show no rales, rhonchi, or dullness, Cardiac examination shows a grade I/IV systolic ejection murmur at the left sternal border without significant gallop or rub. Abdominal examination demonstrates no mass, tenderness, or organomegaly. There were no cervical, supraclavicular, axillary, or inguinal lymphadenopathy. A left inguinal hernia is noted.  Peripheral examination demonstrated no edema or tenderness.

Today’s Laboratory studies (drawn by the Hematologist):

CBC:

• Hemoglobin 9.7 g/dl (normal range, 13.9-16.3)
• Hematocrit 34.2% (41.0-53.0)
• MCV 100.5 (80-100)
•  RDW 17.6% (11.5-14.5)
• Absolute reticulocyte count 221/cu mm
• Platelet count 51,000 /cu mm (150,000-350,000)
• WBC 2130 /cu mm (4500-11000)
• Reported differential:  1% eosinophils (1-4), 1% basophils (0-2), 79% lymphocytes (22-44), 17% neutrophils (40-70)

(Selected images from the blood smear are below.)

Chemistry:

• BUN 12 mg/dl (normal range, 7-22), Creatinine 1 mg/dl (0.6-1.3), Glucose 138 mg/dl (60-109), Total Protein 7.8 g/dl (6.0-8.2), Albumin 4.2 g/dl (3.5-5.3), Alkaline Phosphate 46 IU/l (30-120), LDH 296 IU/l (118-273), PSA 1.7 ng/ml.
• Vitamin B12 466 pg/ml (200-600), TSH 2.07 uIU/ml (0.50-4.50).
• Anti-hepatitis C virus antibody negative, hepatitis B virus surface antigen negative, ANA screen negative.

A diagnostic procedure is performed.

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