Ms. Rand is a 65-year-old woman who spends most of her day sitting on her porch and recovering from a recent surgery involving the removal of suspected cancerous lymph glands in the inguinal area. She is now complaining that her shoes are fitting too tightly, and she has developed poorly healing sores on her legs and ankles. A closer examination also shows distention in her varicose veins. Blood tests reveal a low level of proteins in the plasma.
Mr. Alvis, age 57, presented to his physician with marked fatigue, nausea with occasional diarrhea, and a sore, swollen tongue. Lately, he also has been experiencing a tingling feeling in his toes and a feeling of clumsiness. Microscopic examination of a blood sample indicated a reduced number of erythrocytes, many of which are megaloblasts, and a reduced number of leukocytes, including many large, hypersegmented cells. Hemoglobin and serum levels of vitamin B12 were below normal. Additional tests confirm pernicious anemia.
Mr. Kelly is a 57-year-old man who consulted his physician after noticing marked leg pains while playing golf. He had previously noticed increasing fatigue and discomfort in his legs associated with moderate exercise. When sitting for extended periods with legs dangling, his legs became red, and sometimes his feet felt numb. His history indicates he smokes cigarettes and is chronically overweight. His blood cholesterol and other lipid levels are abnormal, and his physician suspects peripheral atherosclerosis as the cause of his discomfort.