CASE STUDY 5 Mrs. C., a 79-year-old woman, presented to the emergency department barely able to walk. She said that she had gotten progressively weaker in the past couple of weeks and that she had noticed that her appetite was failing. She had seen some yellow color to her eyes and skin, and that worried her. She had no desire to eat but she did crave ice. Mrs. C. was thin, emaciated, and pale; she had difficulty walking and seemed generally confused. CBC and peripheral smear were ordered, with more tests pending the initial results. The initial results were: WBC 4.5 x 10%/L 2.12 x 10°/L 7.5 g/dL 22% 103 fL. 35.3 pg 34.9 105 x 106/L RBC Hgb Hct MCV MCH MCHC Platelets The peripheral smear showed a mixture of microcytes and macrocytes, with target cells, schistocytes, few oval microcytes, rare hypersegmented neutrophils, and occasional hypochromic macrocytes. Because of the mixed blood picture, an iron profile was ordered as well as serum folate and serum vitamin B12. The follow-up blood work showed serum iron of 25 ug/dL (reference range 40 to 150 ug/dL), TIBC 500 µg/dL (reference range 200 to 400 ug/dL), red blood cell folate 100 ng/mL (reference range 130 to 268 ug/dL), and serum vitamin B12 200 Pg/dL (reference range 100 to 700 ug/dL). What type of anemia does this patient have? What do the additional test tell your about her condition? Which conditions show hypersegmented neutrophils? What is the likely cause for this patient’s pancytopenia?
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