This is reactive polycythemia vera, which is due to high altitude or lung disease. SaO2 is low, and EPO is increased.

Another way to approach the question is looking at the blood smear. It's pretty normal (no megakaryocytes, no increased number of platelets, no rods, nothing blue, etc). A blood smear from a COPD patient will be normal. Just an increased number of RBCs due to the increased EPO leading to increased Hgb.

I confused myelodysplastic syndrome with primary myelofibrosis because I thought 2-3 of those RBCs looked like teardrop cells. Just like when they show an image for bullous pemphigoid and there's some weird second rip through the dermal/subdermal layer making me think it's not BP even though I don't know what else it would be. fml

Pt has polycythemia vera (myeloproliferative disorder) due to chronic hypoxia induced by COPD. Myeloid metaplasia is extra medullary hematopoiesis due to myelofibrosis. Hereditary hemochromatosis would have been proven by a prussian blue stain. Hypersplenism would have caused decreased RBCs, and myelodysplasic syndrome would have shown Auer rods or blasts.