Heme Course
Lab Day 1 Tues 2/4/14
[For instructors eyes only]
Learning activity 1: Identification of blood and bone marrow cells (15 min)
Open the Lab 1 Learning Powerpoint and as a table, go through the cells and try and
identify what they are before going on to the annotated slide (next in line) for the
answer. Get assistance from the faculty to help you understand how to distinguish
between cell types in the peripheral blood and bone marrow. Don’t worry about
precise names for immature cells, “immature myleoids” or “immature erythroids”
suffices.
Assist students as they go through approximately 20 different unknown cells. This will
prep them for the quiz at the end of class to see how much they retained. Perhaps go
through some that caused them difficult together at the end of the exercise.
Learning activity 2: The Peripheral Blood Smear
Briefly instruct students on evaluation of peripheral smears using scanned slides on
ImageScope software. Show them how to take snapshots of cells using the camera
button. Image files are loaded on individual computers.
Exercise A. (15 minutes) Examine the slide files #29449 and #6436 [these are
normal and reactive neutrophilia blood smears] on your computer. The CBC on the
patient’s smear #29449 is
WBC 6.5 K
RBC 4.7 M
Hgb 1346
Hct 42
MCV 89
MCHC 35
Platelet 237 K
Abs RTC 47 K
The differential on the WBC is 40% PMN, 49% lymphocytes, 7% monocytes, and
4% eosinophils.
1. What are the absolute neutrophil and lymphocyte counts (roughly)? [ANC 2610,
ALC 3170, AMC 440]
2. Are these within normal limits? [Yes]
3. Identify a neutrophil, a lymphocyte, monocyte, and platelets on the peripheral
smear. Get a feel for the range of morphology that one sees amongst these cells in a
normal smear. Get a feel for the RBC morphology and how it appears to change as
you go from thinner to thicker areas of the smear. No answers required for this
question.
4. Examine slide #6436. What do you predict the CBC and differential to be in this
case compared to the first smear (rough estimate)?
[WBC 38.6, RBC 4.4, Hgb 12.3, Hct 36, MCV 84, MCHC 34, Platelet 238, ANC 35512 with
large % bands, ALC 1158, AMC 1158]
5. What are the major differences between the two slides? [Neutrophilia, bandemia,
occ. immature grans in 3, otherwise similar indices]
6. What is a potential cause of these differences (we will discuss the details of the
case as a group)?
Group discussion of normal smear morphology and questions using computer display
to allow putting up individual group examples of different cell types.
[Actual case history for slide 6436: 12 y.o. F with hx of mild asthma presents to PMD
with 1 day history of fever, HA, non-productive cough, emesis x 3 and a 2 week hx of
mild cough. PE: Nl. Except crackles in LLL and T= 40.2. O2 sat normal. CXR = LLL
pneumonia. Admitted for 1 day on IV antibiotics. Tests included spinal tap, blood
cultures, Influenza A and B PCR, Strep and legionella Ags, all of which were negative.
Discharged on Augmentin and Zithromax and did well].
[Bring up issues of age-related normal ranges of different cell types].
Exercise B: (10-15 minutes) Examine the slide #6343 (normal bone marrow
aspirate) and slide #6000 (normal marrow biopsy). On the aspirate slide, identify
some examples of the various stages of maturation and click “snapshots” of these to
share with the class:
Table 1: A “youngish” immature myeloid cell (promyelocyte/myelocyte)
Table 2: An “oldish” immature myeloid cell (metamyelocyte/band form)
Table 3: An immature erythroid cell
Table 4: A megakaryocyte
Table 5: A plasma cell
2. On the bone marrow biopsy slide identify megakaryocytes, erythroid precursors,
and, if you are able, myeloid precursors and perhaps plasma cells. Get a sense of the
architecture and heterogeneity of the normal bone marrow, with immature myeloid
cells near the bone and mature neutrophils further away. Get a sense of the
clustered or “island” architecture of the small, circular, and dark nuclei of the
erythroid precursors. See if you can see small sinuses.
Go over normal morphology with students, showing their snapshot examples of normal
cells. Using the computer system, individual tables’ examples can be shown on the
main screen in sequence.
Exercise C (5-8 minutes):
Case Problem of the day:
Open the Case Problem Powerpoint file. There are 3 different bone marrow aspirate
and biopsies pictured, #s 1-3. Match them to the following appropriate case
scenarios:
Case A: A 25 year old student has volunteered to be a bone marrow donor
during a signup drive at his workplace for a coworker with acute leukemia
who needs a bone marrow transplant and turns out to be a good match. He is
treated with G-CSF in order to increase his hematopoietic stem cell numbers
for donation.
Case B: A 3 year old girl presents with petechiae on her lower legs and is
found to be pancytopenic. Her blood counts were normal 8 months ago at a
well child check.
Case C: A 25 year old professional bicycle racer presents to the team doctor
with a headache. A CBC shows a hematocrit of 74%.
A “matching” quiz with an AA (Case B, marrow 2), an Epo-treated marrow with
erythroid hyperplasia (Case C, marrow 1), and G-CSF treated marrow with myeloid
hyperplasia (Case A, marrow 3). Go over answers briefly with all students.
Learning Activity 3 (15 minutes)
Quiz (non-graded): Open the Hemelab 1 Quiz Powerpoint.
Identify the cells pictured in categories similar to those we used at the beginning of
class.
To submit your group answers, create a Word Document titled “Quiz Day 1”, with
your Room number and Table number. List out the answers, 1-10. When finished,
save document to your desktop (eg Quiz1.2272.table4.doc)and then deposit file in
the Upload folder on the H Drive in the appropriate sub-folder. If you save directly
to these folders it does not work.
Students will go through 10 slides and identify the cells
Answers:
1- Eosinophils
2- Band neutrophils
3- Megakaryocytes
4- Monocytes
5- Immature erythroids
6- Plasma cells
7- Immature myeloids
8- Neutrophils (with toxic gran and dohle bodies)
9- Lymphocytes
10- Basophils