A CBC shows severe anemia with macrocytosis and a hypercellular marrow with dysplastic changes in two lineages. What is the presumptive diagnosis?

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Macrocytosis with a hypercellular marrow and dysplasia in more than one hematopoietic lineage points to a myelodysplastic process. This pattern reflects ineffective hematopoiesis due to clonal marrow dysplasia, typically presenting as anemia with pronounced macrocytosis. Refractory anemia fits Best as a presentation within this spectrum where anemia is the dominant issue and there is dysplasia in the marrow. Aplastic anemia would show a hypocellular marrow, so that doesn’t match. Megaloblastic anemia can also show macrocytosis and a cellular marrow, but the dysplasia described across two lineages is more characteristic of a myelodysplastic syndrome rather than a purely nutritional megaloblastic process. Thus, the presumptive diagnosis is refractory anemia (a form of myelodysplastic syndrome).