HAEMATOLOGY Richard Shaw

1

Haematological History History of Presenting Complaint

Associated Symptoms:

o Bruise easily?

o Fevers, shivers or shakes (rigors)?

o Difficulty stopping a small cut from bleeding?

o Lumps under your arms, in your neck or groin?

Past Medical History

Ever had any blood clots in your legs or lungs?

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Differential Diagnosis of Common Presentations Anaemia

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Easy Bruising/Bleeding Tendency (Bleeding Diathesis) Causes

Clinical Features

Vascu

lar Diso

rde

rs

Cong

Infec

Inflam

Meta

Degen

Drugs

Osler-Weber-Rendu syndrome

CT disorder (Ehlers-Danlos)

Psuedoxanthoma elasticum

Meningococcal

Measles

Dengue fever

Henoch-Schonlein purpura

Scurvy

Senile purpura

Steroids

Trauma

Co

agulo

path

y

Cong Haemophilia A (VIII def – X link)

Haemophilia B (IX def – X link)

Von Willenbrand’s disease

Haemophilia

Degen Liver disease

Vasc DIC

Meta Vitamin K deficiency

Malabsorption (TV channel def)

Inflam Acquired haemophilia (Ig vs VIII)

Drugs Anticoagulants (e.g. warfarin)

Malnutrition

Hx

HPC

o Trauma

o Pattern of bleeding

Extensiveness and severity

Prolonged cut bleeding, bleeding

into skin and bleeding from

mucuous membranes suggest

vascular platelet problems

OE - Bruises

Distribution

o Truncal/Back/Face bleeding

should raise suspicion of

bleeding diathesis or abuse

o Type

Petechiae

Pinhead size

Usually platelet

Po

or Fu

nctio

n

Platelet D

isord

ers

Infec

Neo

Vasc

Meta

Degen

Drugs

Viruses (CMV, EBV, HIV)

Blood malignancy (Leuk, Lymph, Myel)

Myeloma (via marrow suppression)

Aplastic anaemia

Megaloblastic anaemic

Hypersplenism (sequestration)

Thro

mb

ocyto

po

enia (R

edu

ced P

rod

uctio

n/ D

estructio

n)

Marrow Suppression (chemo, radio)

Immune Thrombocyotpoenic Purpura

SLE

Inflam

Heparin (HITS)

Renal failure

DIC

Drugs

Neo Myeloproliferative Disease

NSAIDs

Hyperuraemia

HELLP Syndrome

Rheumatoid Arthritis

Malaria

Sepsis

Antimalarials

Chemotherapy

Anti-epileptics

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Investigations Bloods

FBC o Thrombocytopoenia

LFTs o Liver disease

Coag panel o INR Dependent on Fs V, VII, X and fibrinogen Sensitive to warfarin

o APTT

Dependent on Fs V, VIII, IX, X, XI, XII, prothrombin and fibrinogen

Sensitive to heparin

OE – Other findings

Stigmata of liver disease

Cachexia

o Malignancy

o Malnutrtition

Poor dental hygiene

o Scurvy

Lymphadenopathy

o Infection

o CT disease

o Malignancy

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Lymphadenopathy Causes Infec Bacterial

o Streptococcal pharyngitis o Pyogenic o TB o Brucella o Syphillis

Viral o EBV o HIV o Adenovirus o CMV o HZV o Infectious hepatitis

Others o Toxoplasmosis o Trypanosomiasis

Neoplastic Malignant o Haematological Lymphoma Leukaemia (ALL, CLL, AML)

o Metastatic carcinoma Breast Lung Bowel Prostate Kidney Head and neck

Inflammatory Sarcoidosis

Amyloidosis

Berylliosis

CT disease (RA, SLE)

Dermatological (eczema, psoriasis)

Drugs Phenytoin

Retrovirals

Clinical Features

Investigations Biopsy if lump hasn’t resolved over 4 weeks or with findings suggestive of malignancy

Bloods Imaging Invasive

FBC CXR FNA

Core needle biopsy

Open biopsy

Localising signs of

infection/malignan

cy

Constitutional

symptoms (fever,

night sweats, wt

loss)

Medications

Exposures

o Injury

o Undercooked

meat (toxo)

o Tick bite (lyme)

o High risk

behaviour (sex,

drugs)

o Travel

Hx

Splenomegaly suggests malignancy or EBV

Nodes

Location

Size

Shape

Consistency

Fixation

Tenderness

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Examination Ask patient if he/she is comfortable to lie flat, with head

on pillow, arms resting by sides.

General Observation Wasting and Pallor

o Anaemia

o Chronic disease

Ethnicity

o Thalassaemia

Purpura (Petechiae → Ecchymoses)

o Petechiae

Thrombocytopenia/platelet

dysfunction

Bleeding from small vessel disease

Infection

o IE, septicaemia,

viral exanthemata

Drugs (e.g. steroids)

Vasculitis

o Polyarteritis

nodosa

o HSP

o Ecchymoses

Thrombocytopenia/platelet

dysfunction, trauma

Coagulation disorders (vit K deficiency,

liver disease, anticoagulant drugs,

congenital, DIC)

Senile Ecchymoses

Jaundice

o Haemolytic anaemia

Excoriations/Scratch Marks (Pruritus)

o Lymphoma

o Myeloproliferative disease

Hands/Wrists Nails

o Koilonychia

Iron deficiency anaemia

Fingers

o Digital Gnfarction

Abnormal globulin

o Rheumatoid Arthritis

Skin abnormalities, swelling

Swan neck, Boutonniere deformity

Z deformity of the thumb

Felty's Syndrome → also associated

with: Thrombocytopenia, haemolytic

anaemia, skin pigmentation, leg

ulceration

o Gouty Arthritic Changes

Tophi + arthropathy

Myeloproliferative diseases

Palms

o Palmar crease pallor

Anaemia

Pulse

o Tachycardia → anaemia

Arms Purpura (Petechiae → Ecchymoses)

o Palpable purpura (raised)

Systemic vasculitis or bacteraemia

Epitrochlear Nodes

o Elbow flexed to 90°

o Local infection, Non-hodgkin lymphoma

o Sarcoidosis, Syphilis

Axillary Nodes

o Right hand for left axilla and vice versa

o 5 groups - ant, post, lat, central, apical

Upper limb infection, immunisation

Breast carcinoma, disseminated

malignancy + generalised causes

A= central, B=lateral, C=pectoral, D=infraclavicular, E=subscapular

Face Eyes

o Scleral icterus

Haemolytic anaemia

o Haemorrhage

o Conjunctival pallor

Anaemia

Lips/Mouth

o Hypertrophic gingivae

Acute monocytic leukaemia

Scurvy

o Gingivae, buccal, pharyngeal mucosa

Ulceration, infection, haemorrhage

o Atrophic Glossitis/Angular stomatitis

Megaloblastic anaemia

Iron deficiency anaemia

o Lip/Mouth telangiectasia

Hereditary haemorrhagic

telangiectasia

o Enlarged tonsils (Waldeyer's ring)

Non-Hodgkin's lymphoma

Neck Sit patient up

Cervical Lymph Nodes

o All 8 groups of lymph nodes

o Infection of metastatic malignancy (chest,

abdomen (stomach), pelvis, oesophagus)

o Lymphoma, generalised causes (see below)

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Generalised Lymphadenopathy

o Lymphoma (rubbery and firm)

o Leukaemia (CLL, ALL)

o Infections (e.g. EBV, CMV, HIV, TB)

o Connective Tissue Diseases e.g. RA, SLE

o Infiltration e.g. sarcoidosis

o Drugs e.g. phenytoin

Axial Skeleton

o Press on sternum and clavicles w/ heels of hands

o Press both shoulders together

o Tap over each vertebrae with fist

Bony tenderness

Infiltration of metastases

Primary bone malignancy

Abdomen Lay patient flat again - ideally perform full abdominal examination

but of particular importance are:

Liver Palpation/Percussion

o Hepatomegaly

Metabolic

Fatty liver (DM, obesity,

EtOH), Storage diseases

Infective

Infective monocleosis,

hepatitis A, B, malaria, liver

abscess or cyst

Neoplastic

HCC, met., haemangioma,

leukaemia, lymphoma

Infiltrative

Amyloidosis, sarcoidosis,

haemachromatosis,

Anatomical (Reidel's lobe)

Vascular

Heart failure, Budd-Chiari

Spleen Palpation

o Splenomegaly (TnO p230) ICHINI

Infection

EBV, Hep., CMV, TB, HIV, IE

Congestive

Portal hypertension from:

cirrhosis, CHF, venous

thrombosis/obstruction

Haematological

Lymphoma, leukaemia,

myeloproliferative, congenital

Inflammatory

SLE, RA, Sarcoidosis

Neoplastic

Met., haemangioma

Infiltrative

Amyloidosis, Gaucher's

Hepatosplenomegaly

o Chronic liver disease with portal hypertension

o Haematological (lymhoma, leukaemia, sickle

cell/pernicious anaemia)

o Infection (acute viral hepatitis, CMV)

o Infiltration (amyloid, sarcoid) and CT (SLE)

o Acromegaly, thyrotoxicosis

Kidney vs Spleen

o Spleen has no palpable upper border

o Spleen has a notch and moves inferomedially and

kidneys move inferiorly with inspiration

o Only kidneys are ballotable (retroperitoneal)

o Splenic percussion is dull, kidneys resonant

o Friction rub may be heard over spleen

Regional Lymph Nodes

o Para-aortic (central, deep abdominal masses)

Lymphoma or Lymphatic leukaemia

o Inguinal

Inspect/palpate for testicular masses

Rectal Examination

o Evidence of bleeding

o Carcinoma

Legs Inspection

Purpura

o Palpable purpura over legs/buttocks

Henoch-Schonlein purpura

Pigmentation and Scratch Marks

Leg Ulcers

o Haemolytic anaemia (above both malleoli)

Sickle cell anaemia

Hereditary spherocytosis

o Thalassaemia

o Macroglobulinaemia

o Thrombotic thrombocytopenic purpura

o Polycythaemia

o Felty's syndrome

Palpation

Popliteal lymph nodes (rarely felt)

Haematological Examination Summary

I performed a haematological examination on Mr/Mrs. X

who is a X old male/female who presented with X.

Major findings were:

o Most significant finding → second most

significant or findings related to most

significant finding (positive and negative)

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My other findings were:

o No peripheral signs of X, Y or any other

haematological disease

o Abdomen was soft and non-tender to palpation

with no localized masses

o Liver span was X cm and no organomegaly was

palpated: liver and spleen unpalpable

o No bony tenderness in the axial skeleton

o No palpated lymph nodes were enlarged

including epitrochlear, axillary, cervical, para-

aortic and inguinal lymph nodes were palpable

Based on my current findings, my provisional diagnosis

is X with differentials including X, Y, Z.

Ideally I would also like to:

o Anything up to inguinal lymph nodes that was

not performed

o Perform a rectal (and scrotal) examination

specifically looking for evidence of bleeding or

carcinoma

o Examine the legs for peripheral signs of X, Y or

other haematological disease

o Perform fundoscopy

The investigations I would like to perform are X, Y, Z

(specifically looking for x, y, z).

Lower Limb Neurological Assessment

Vitamin B12 deficiency

o Peripheral neuropathy

o Subacute combined spinal cord degeneration

Lead poisoning

o Anaemia

o Foot (+wrist) drop

Fundoscopy

Haemorrhage

Engorged veins and later papilloedema,

o Hyperviscosity → macroglobulinaemia,

myeloproliferative disease, chronic granulocytic

leukaemia

Special Tests

Hess test

o If thrombocytopenia or capillary fragility

suspected

o BP cuff inflated on forearm between SBP and

DBP for 10 minutes. After removing cuff the

number of petechiae is counted within a 5cm

diameter of area under pressure. > or = 15

indicates a positive test.