1
Faculty:
Case Number: HB- -
Patient Name:
Diagnosis
Peripheral Blood:
- Normochromic hypochromic anemia
Bone Marrow:
- Normocellular for age
- No morphologic or immunophenotypic evidence of
- Adequate iron stores
Comment
-Immunophenotyping of bone marrow aspirate by flow cytometry (report HF- - ) shows
-Bone marrow aspirate was sent for cytogenetics, FISH panel for
Tumor Summary
Specimen:
Peripheral blood smear
Bone marrow aspiration
Bone marrow aspirate clot
Bone marrow core (trephine) biopsy
Bone marrow core touch preparation (imprint)
Procedure: Bone marrow
Aspiration site: R posterior iliac crest
Biopsy site: R posterior iliac crest
Histologic type:
Immunophenotyping
Immunohistochemistry: Performed
Flow cytometry:
Performed, see separate report (HF-xx-_)
Cytogenetic studies: Performed, see separate report
Specimen Source
1. Bone marrow aspirate and clot
2. Bone marrow core biopsy, decal, touch prep
3. Peripheral blood smear
Bone marrow procedure was performed by IR
Clinical Information
.
Gross Description
[by Surg Path]
Microscopic Description
CBC Results
Date/time:
PERIPHERAL BLOOD:
Erythrocytes: Normochromic hypochromic anemia with anisopoikilocytosis, mild polychromasia
White cells: Normal in number
Granulocytes: Normal morphology
Lymphocytes: Normal morphology
Monocytes: Normal morphology
Platelets: Normal number and morphology
Bone marrow
Differential (%)
Myeloblasts:
Promyelocytes:
Myelocytes:
Metas:
Bands & PMN's:
Eos:
Baso:
Monos:
Lymphs:
Plasma cells:
Erythroids:
M:E ratio
Cellularity: %, normocellular for age
Megakaryopoiesis: Adequate with normal maturation
Erythropoiesis: Adequate with normal maturation
Iron Content (aspirate): Adequate iron stores
Granulopoiesis: Adequate with normal maturation
Lymphocytes: Normal number and morphology
Plasma Cells: Normal number and morphology
Biopsy and clot section: No evidence of granuloma, fibrosis or abnormal cellular infiltrates
Iron content (biopsy and clot section):Adequate iron stores
Intradepartmental Consultation
-This casewasreviewedwitha consensus at theUniversityof Texas-Houston MedicalSchoolHematopathologyQAConferenceon xx/xx/xxxx.
Non Clinical Documentation
CPT:88305 x 2, 88313 x 2, 88311, 85097, 85060, 88342, 88341 x
The positive controls and internal negative controls for the special stains have been reviewed, and appropriate staining is confirmed by the pathologist whose signature appears above.
Some of theimmunohistochemicaltests in this panel were developed and their performance characteristics determined by Memorial Hermann Southwest Hospital Laboratory.They have not been cleared or approved by the U. S. Food and Drug Administration.The FDA has determined that such clearance or approval is not necessary.These tests are used for clinical purposes.They should not be regarded as investigational or for research.This laboratory is regulated under the Clinical Laboratory Improvement Amendments of the 1988 (CLIA) as qualified to perform high complexity clinical testing.
Teaching Physician Statement
"I have personally reviewed the resident's preliminary interpretation and all specimen preparations and have personally issued this report".