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HAEMATOLOGY

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?

Richard Shaw

HAEMATOLOGY

Differential Diagnosis of Common Presentations


Anaemia

Richard Shaw

HAEMATOLOGY

Richard Shaw

Easy Bruising/Bleeding Tendency (Bleeding Diathesis)


Causes
Haemophilia

Haemophilia A (VIII def X link)

Cong

Haemophilia B (IX def X link)

DIC
Infec

Vasc

Acquired haemophilia (Ig vs VIII)

Inflam

Malaria

Liver disease

Degen

Sepsis

Vitamin K deficiency

Meta

Blood malignancy (Leuk, Lymph, Myel)

Malabsorption (TV channel def)

Myeloma (via marrow suppression)

Malnutrition

Aplastic anaemia

Anticoagulants (e.g. warfarin)

Drugs

Osler-Weber-Rendu syndrome

Cong

Megaloblastic anaemic
DIC
Inflam

Immune Thrombocyotpoenic Purpura


SLE
HELLP Syndrome
Rheumatoid Arthritis

Degen

Hypersplenism (sequestration)
Renal failure

Drugs

Heparin (HITS)
Antimalarials
Marrow Suppression (chemo, radio)
Chemotherapy
Anti-epileptics

Poor Function

Neo

Myeloproliferative Disease

Meta

Hyperuraemia

Drugs

NSAIDs

CT disorder (Ehlers-Danlos)
Psuedoxanthoma elasticum
Meningococcal

Infec

Measles
Dengue fever
Henoch-Schonlein purpura

Inflam

Trauma
Senile purpura

Degen

Scurvy

Meta

Steroids

Drugs

Vascular Disorders

Platelet Disorders

Thrombocytopoenia (Reduced Production/ Destruction)

Neo

Viruses (CMV, EBV, HIV)

Vasc

Coagulopathy

Von Willenbrands disease

Clinical Features
Hx

OE - Bruises

HPC
o Trauma
o Pattern of bleeding
Extensiveness and severity
3
Prolonged cut bleeding, bleeding
into skin and bleeding from
mucuous membranes suggest
vascular platelet problems

Distribution
o Truncal/Back/Face bleeding
should raise suspicion of
bleeding diathesis or abuse
o Type
Petechiae
Pinhead size
Usually platelet

HAEMATOLOGY

Richard Shaw

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

Investigations

FBC
o Thrombocytopoenia
LFTs
o Liver disease

Bloods
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

HAEMATOLOGY

Richard Shaw

Lymphadenopathy
Causes

Infec

o
o
o
o
o

o
o
o
o
o
o

o
o
Inflammatory

Bacterial
Streptococcal pharyngitis
Pyogenic
TB
Brucella
Syphillis
Viral
EBV
HIV
Adenovirus
CMV
HZV
Infectious hepatitis
Others
Toxoplasmosis
Trypanosomiasis
Sarcoidosis
Amyloidosis
Berylliosis
CT disease (RA, SLE)
Dermatological (eczema, psoriasis)

Neoplastic

Malignant
Haematological

Lymphoma

Leukaemia (ALL, CLL, AML)


o Metastatic carcinoma

Breast

Lung

Bowel

Prostate

Kidney

Head and neck


o

Drugs

Phenytoin
Retrovirals

Clinical Features
Hx

Localising signs of
infection/malignan
cy
Constitutional
symptoms (fever,
night sweats, wt
loss)
Medications

Nodes

Exposures
Injury
Undercooked
meat (toxo)
o Tick bite (lyme)
o High risk
behaviour (sex,
drugs)
o Travel

o
o

Location
Size
Shape
Consistency
Fixation

Splenomegaly suggests malignancy or EBV

Investigations

Biopsy if lump hasnt resolved over 4 weeks or with findings suggestive of malignancy
Bloods

FBC

Imaging

Tenderness

CXR

Invasive

FNA
Core needle biopsy
Open biopsy

HAEMATOLOGY

Richard Shaw

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

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

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

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)

HAEMATOLOGY

Richard Shaw

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
o

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

Inspect/palpate for testicular masses

HCC, met., haemangioma,

Rectal Examination
leukaemia, lymphoma
o Evidence of bleeding

Infiltrative
o Carcinoma

Amyloidosis, sarcoidosis,
Legs
haemachromatosis,
Inspection

Anatomical (Reidel's lobe)

Purpura

Vascular
o Palpable purpura over legs/buttocks

Heart failure, Budd-Chiari

Henoch-Schonlein purpura

Spleen Palpation

Pigmentation and Scratch Marks


o Splenomegaly (TnO p230) ICHINI

Leg Ulcers

Infection
o Haemolytic anaemia (above both malleoli)

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

Sickle cell anaemia

Congestive

Hereditary spherocytosis

Portal hypertension from:


o Thalassaemia
cirrhosis, CHF, venous
o Macroglobulinaemia
thrombosis/obstruction
o Thrombotic thrombocytopenic purpura

Haematological
o Polycythaemia

Lymphoma, leukaemia,
o Felty's syndrome
myeloproliferative, congenital
Palpation

Inflammatory

Popliteal lymph nodes (rarely felt)

SLE, RA, Sarcoidosis

Neoplastic
Haematological Examination Summary

Met., haemangioma

I performed a haematological examination on Mr/Mrs. X

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

Amyloidosis, Gaucher's

Major findings were:

Hepatosplenomegaly
o Most significant finding second most
o Chronic liver disease with portal hypertension
significant or findings related to most
significant finding (positive and negative)

HAEMATOLOGY

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, paraaortic 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.

Richard Shaw