HAEMATOLOGY Richard Shaw
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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.