2 down, 8 to go

During a routine doctor's visit, a 68-year old man is found to have an increased white blood cell count with normal RBC and platelet counts.  He reports to be in good health.  His peripheral blood smear is shown here. 

What is his most likely diagnosis?

1. Acute lymphoblastic leukemia
2. Chronic myelogenous leukemia
3. Chronic lymphocytic leukemia
4. Acute myelogenous leukemia
5. B12 deficiency

     I stared at this question for a long while, not because I didn't know the answer.  I definitely knew the answer.  I knew it all too well.  It was a textbook example of CLL.  And that was my problem.  How often do diseases follow the textbook?  I know from my research days that the lab animals rarely read the relevant literature and often didn't do what they were supposed to do.  And from my own personal family, 2 for 2 on completely non textbook diseases. 

     This has been a hard block for me.  Lots of cancer stuff and lots of emotions along with it.  And hard not to argue with the professors because I knew so well that cancer doesn't play by nice and tidy rules.  Intellectually I know we have to start with the basics and that "common stuff is common".  But when you learn a piece of information experientially and process it with intense emotions, logic doesn't really matter as much.  So I bubbled in the third answer choice and finished the 100 question pathology exam.  Went home, worked out and started studying for the next exam.  It's Fundamentals of Clinical Medicine.  Arthritis, anemia, and of course, cancers.