Required section · Section 1 of 5
The bounded question
A 31-year-old outpatient has K2EDTA whole blood collected at 09:10 and analyzed at 09:35. Physically inspect the tube—not the instrument status alone—for adequate fill and a visible clot before proceeding; then confirm identity/timing and review analyzer errors, flags, and scatter information under the local procedure. The analyzer's five-part differential reports neutrophils 78% (no band result). A locally triggered 100-cell manual smear differential reports segmented neutrophils 78% and bands 2%; the analyzer IG flag is a separate instrument prompt, not a cell percentage.
This teaching laboratory's local ANC convention is WBC × (segmented-neutrophil fraction + manual-band fraction): 14.8 × (0.78 + 0.02) = 11.8 × 10^9/L. Analyzer IG, when reported by a method, is not added to ANC under this local convention; an IG flag is not an IG count. The local adult teaching interval is 1.8–7.7 × 10^9/L, so the ANC is above that interval. A percentage describes distribution; it does not itself establish an increased cell number.
One bounded workflow governs review of a flagged neutrophilia result: specimen/analyzer validity; absolute counts; local smear rule; flag resolution; release or escalation. It does not diagnose infection, marrow production, or neoplasm. The analyzer supplies counts, categories, flags, and instrument information; the quality smear supplies morphology only when the local review rule is met. Local policy, not a generic teaching workflow, defines review triggers, repeat/rerun rules, delta limits, reporting comments, urgency, and referral criteria.
Illustrative drawing — this picture was drawn rather than captured.
| Component | Differential source | Reported fraction | Absolute count × 10^9/L | Local adult teaching interval × 10^9/L |
|---|---|---|---|---|
| WBC | Analyzer CBC | — | 14.8 | — |
| Segmented neutrophils | 100-cell manual smear differential | 78% | 11.5 | 1.8–7.7 ANC (local convention includes manual bands) |
| Bands | 100-cell manual smear differential | 2% | 0.30 | Included only because manual differential supplied them |
| Analyzer IG / IG flag | Analyzer method / instrument prompt | Not used in case | Not added to ANC | Separate from manual bands and ANC |
One locally governed workflow for a flagged neutrophilia result
Inspect specimen and instrument context
Confirm identity and timing; physically inspect the tube for adequate fill and visible clot; then review analyzer errors, flags, and scatter information under local criteria.
Calculate and compare the local ANC
Calculate locally defined absolute counts. In this case, ANC = WBC × (segmented neutrophils + manual bands); do not add analyzer IG or an IG flag.
Resolve the flag on a quality smear
When the local rule requires review, assess an acceptable Wright-Giemsa smear for the reported feature, artifacts, bands/immature granulocytes, blasts, dysplasia, and other lineages; resolve the IG flag by documented findings and the stated next step.
Compare a dated prior CBC
Record the collection date and result when available; it supplies duration evidence, not a diagnosis.
Release or escalate locally
Document the verified pattern and follow the established review, communication, and referral pathway.
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