We are investigating a 68 year old lady referred with a macrocytic anaemia and thrombocytosis. Thanks for all of your helpful input thus far. Tests you have requested to date:

Haemoglobin              87 g/L (115 – 165)

White cell count          5.2 x 10⁹/L (4 – 11)

Platelets                      538 x 10⁹/L (150 – 450)

Mean Cell Volume      108 fl (80 – 100)

Folate/B12 – normal

LFTs – normal

Ferritin – normal (with a normal CRP)

Retics – borderline low

Haemolysis screen (LDH, DAT) – negative

Coag screen – negative

CT chest, abdomen, pelvis – no evidence of malignancy. No size significant lymphadenopathy and normal liver/spleen. Confirms previous right total hip replacement.

Blood film is prepared and shown below (the BMS comments that there is a lot of platelet clumping and platelet islands, and confirms a thrombocytosis):

What does the blood film demonstrate? What would be the next step in your investigation of this lady?

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