Routine CBC with Mild Abnormalities in Young Male

Case at a Glance

A 29-year-old male with a history of smoking and anxiety presented for routine complete blood count (CBC) evaluation. The patient reported occasional headaches and was concerned about laboratory values that appeared outside normal reference ranges.

Patient's Story

The patient, a former smoker with a documented history of anxiety disorder, sought medical evaluation for routine health screening. His primary concern was intermittent headaches localized to the occipital region and supraorbital area. He had no other significant symptoms and was otherwise feeling well. The patient became anxious after reviewing his CBC results, which showed some values outside the reference ranges provided by the laboratory.

Initial Assessment

Physical examination was unremarkable. The patient appeared well with stable vital signs. His primary care physician ordered a complete blood count as part of routine health maintenance. The patient's anxiety was noted to be elevated due to concerns about the laboratory results.

The Diagnostic Journey

The CBC revealed the following key findings: White blood cell count within normal limits, absolute lymphocyte count of 2.89 × 10³/μL (reference range 1.0-3.0), and a mildly elevated red cell distribution width (RDW-CV). The primary care physician, noting the lymphocyte percentage and RDW elevation, recommended hematology consultation for further evaluation.

Final Diagnosis

Normal complete blood count with no evidence of hematologic malignancy or significant pathology. The absolute lymphocyte count was within normal limits (2.89 × 10³/μL, normal 1.0-3.0). The mildly elevated RDW-CV was determined to be of no clinical significance.

Treatment Plan

Reassurance and patient education regarding normal laboratory values. The hematology consultation was deemed unnecessary given the normal absolute cell counts. The patient was advised that percentage values should be interpreted in conjunction with absolute counts, and his results were within normal parameters.

Outcome and Follow-up

The patient was reassured that his CBC results were normal and healthy. All three cell lines (white blood cells, red blood cells, and platelets) were within expected ranges. The patient was advised to continue routine health maintenance and follow up with his primary care physician as needed. No further hematologic evaluation was required.