Workup/Results 

Physical examination findings Vital signs are unremarkable. In general, this is a well-appearing older male patient in no acute distress, breathing comfortably at rest. Pulmonary examination is positive for expiratory wheezing in the bilateral lung fields. Cardiac examination reveals a regular rhythm and rate, with no audible murmurs. Abdominal examination is positive for a mildly distended abdomen with palpable splenomegaly extending approximately 10 cm below the left costal margin, mid-clavicular line. Bilaterally equal nonpitting edema in the lower extremities is noted.

Laboratory test results CBC with differential: WBC 24.2×109/L with no circulating blasts, neutrophils 60%, lymphocytes 30%, Hgb 10.7 g/dL, MCV 90, PLTs 118×109/L. Chemistry panel reveals mild elevation in alkaline phosphatase (130 U/L) and elevated LDH (700 U/L), otherwise normal hepatic function and serum creatinine is within normal limits (0.8 mg/dL). Iron panel within normal limits 

Imaging Echocardiography reveals increased pulmonary artery pressure concerning for pulmonary hypertension, no evidence of heart failure with normal ventricular function, and left ventricular ejection fraction of 60%. Abdominal ultrasound reveals splenomegaly measuring approximately 18 cm. The patient is referred to hematology/oncology for further work-up.

What is the greatest concern given the above laboratory findings and what additional studies need to be pursued?

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