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INTERNATIONAL MEDICAL UNIVERSITY

MALAYSIA

Bachelor of Medicine &


Bachelor of Surgery

Intake ME 2/16
Semester 2

A Guide to the Haematology System


(May 2017 – June 2017)

Clinical Skills Department


HAEMATOLOGY MODULE

INTRODUCTION

During the five weeks of this module you will cover the basic science of diseases
involving haemopoietic system. The lifelong production of blood cells occurs in
haemopoietic tissue.

The reticulo-endothelial system comprises the spleen, liver, lymph nodes and
lymphatic ducts and lymphoid tissues. The bone marrow produces the cells which
are found in these tissues & organs, and the blood which circulates throughout the
body. In certain situations, haemopoiesis may occur outside the bone marrow
(extra-medullary haemopoiesis).

At birth, haemopoietic activity is distributed throughout the human skeleton but it


gradually recedes with time so that in normal adult life haemopoiesis is found
mainly in the sternum and pelvis, with small amounts in other bones like the ribs,
skull and vertebrae.

In the clinical skills sessions you will learn to interview patients presenting with
haematology problems and to perform physical examination pertaining to the
haemopoieic system.

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Why haematology module is important?

Haematology is an exciting discipline which encompasses both clinical and


laboratory aspects of primary disorders of the blood as well as how other diseases
affect the blood. Primary haematological diseases include the various forms of
leukaemia and lymphoma, some forms of anaemia and diverse blood clotting
disorders. Transfusion medicine also falls into the speciality of haematology.Having
the knowledge of haematology helps the students to understand the basic
pathophysiology of each haematological disease.Thus, students are able to think
critically while performing physical examination. Adequate knowledge of disease
and relevant examination findings guide them to have an accurate diagnosis and
efficient management of the patient.

Learning outcomes:

By the end of this module you will be able to:

Communication skills
1. To elicit a comprehensive family history from a patient.
2. To summarize a patient history in an organized and concise manner
3. To communicate effectively with patients while carrying out an invasive
procedure
4. To obtain consent from a patient to perform a procedure/physical
examination

Clinical examination skills

➢ To systematically examine a “lump” detected on examination and to


relate the examination findings to the likely pathology.

➢ To demonstrate examination of the cervical and axillary lymph nodes.

➢ To accurately describe a skin rash.

➢ Putting All Together is to reinforce clinical reasonings and introduce to early


differential diagnoses.

Practical skills

➢ To safely and effectively carry out venepuncture on a mannequin.

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Session outline

Clinical Skills Haematology Module

Week 1: Examination Week 3:


of lymph nodes and a Week 4: Putting
Venepunture all together
“lump”

Week 2: History taking in a


patient presenting with
tiredness/bleeding/follow up
history from a thalassemia
patient

WEEK 1: PHYSICAL EXAMINATION

Learning Outcomes

At the end of the session, students should be able to:


1. To demonstrate examination of cervical and axillary lymph nodes
2. Examine a lump , describe it and relate the examination findings to the
likely pathology
3. To accurately describe a skin rash

4. Report the cervical and axillary lymph nodes findings correctly

Please view the video on the examination of the Haemopoietic System on your own
from the IMU E-Learning Portal before your clinical teaching session in the Skills
Centre.

Examination of The Lymph Nodes - Dr. Christine


http://elearn.imu.edu.my/mod/page/view.php?id=12209

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References:

You are strongly encouraged to read the following chapters from textbooks in the
library for a better idea on what is a complete physical examination to the
haematological system.

• Clinical Examination: A Systemic Guide to Physical Diagnosis. 7th Edition.


Nicholas J. Talley and Simon O’Connor. Section 6 The Haematological
System

• Chamberlain’s Symptoms and Signs in Clinical Medicine – An Introduction to


Medical Diagnosis. 13th Edition. Chapter 17 The Haematological System

• Oxford Handbook of Clinical Haematology. 3rd Edition. Chapter 1 Clinical


Approach

For a detailed examination of a lump

http://www.oxfordmedicaleducation.com/clinical-examinations/lump-bump-examination

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The examination may be summarized as in the table below:

Haematological System Examination


Lying flat (1pillow)

1. GENERAL INSPECTION 5. CERVICAL NODES (sitting up)


a. Pallor (Anaemia) Palpate from behind
b. Bruising (thrombocytopaenia, scurvy
etc) 6. BONY TENDERNESS
i. Petechiae (pinhead bleeding) a. Sternum
ii. Ecchymoses (large bruises) b. Clavicles
c. Pigmentation (lymphoma) c. Shoulders
d. Rashes and infiltrative lesions d. Spine
(lymphoma(
e. Ulceration (neutropaenia) 7. ABDOMEN (lying flat) and
f. Cyanosis (polycythaemia) GENITALIA
g. Plethora (polycythaemia) Detailed examination
h. Jaundice (hemolysis)
i. Scratch marks (myeloproliferative 8. INGUINAL NODES
disease)
9. LEGS
2. HANDS a. Vasculitis (Henoch-Schönlein
a. Nails – koilonychia purpura – buttocks, thighs)
b. Palmar crease pallor (anaemia) b. Bruising
c. Arthropathy (haemophilia, c. Pigmentation
secondary gout, drug treatment, d. Ulceration
etc) e. Neurological signs (subacute
d. Pulse combined degeneration,
peripheral neuropathy)
3. ARMS
a. Epitrochlear nodes (non-Hodgkin’s 10. OTHER
lymphoma, chronic lymphocytic a. Fundi (hyperviscosity,
leukaemia, intravenous drug use, haemorrhages, infection, etc)
sarcoid) b. Temperature chart (Infection)
b. Axillary lymph nodes c. Urine analysis (haematuria,
bile, etc)
4. FACE d. Rectal examination (blood loss)
a. Sclera – jaundice, pallor, conjunctival
suffusion (polycythaemia)
b. Mouth – gum hypertrophy (acute
leukaemia), ulceration, infection,
haemorrhage (marrow aplasia, etc),
atrophic glossitis, angular stomatitis
(iron, vitamin deficiencies)
c. Tonsils – enlarged (lymphoma)

Taken from Examination Medicine. 6th Edition. Nicholas J Talley and Simon O’ Connor,
Section 15, page 317

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You should be able to describe the lymph node swelling based on the
following criteria
• SITE
• SHAPE AND SIZE
• CONSISTENCY
o Rubbery – suggestive of lymphoma
o Hard – suggestive of carcinoma
o Matted – sometimes found in tuberculosis
• MARGIN

• ATTACHMENTS / FIXATION
o To skin or deep structures
o If fixed to underlying structures, more likely to be infiltrated by
carcinoma
• TENDERNESS – implies infection or acute inflammation
• OVERLYING SKIN
o Inflammation of overlying skin suggest infection
o Tethering to the overlying skin suggest carcinoma

General description of a lump

Inspection:
• Site – describe in relation to fixed anatomical landmarks
• Size and shape
• Colour of skin – e.g. red, pigmented
• Abnormaility of skin – e.g. peau d’orange in breast carcinoma
• Abnormal vessels
• Visible pulsations - aneurysm (abdominal mass)

Palpation:
• Tenderness – ask for this first
• Temperature
• Size – measurement with a tape measure or ruler in 2 dimensions
Eg:(5x5cm )
• Shape- Oval, spherical or round
• Consistency – soft, firm, hard, rubbery, lobulated
• Surface – smooth, rough, irregular , flat or raised
• Margins – well defined or ill defined
• Mobility
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• Fixation - is it tethering of the skin or is it attached to the underlying
structures
• Fluctuation – indicates presence of fluid ( Dermoid cyst)
• Pulsations or thrills

For a detailed examination of a lump

http://www.oxfordmedicaleducation.com/clinical-examinations/lump-bump-examination/

Gentle reminder!
1. Please palpate the lump gently eventhough you only examine the model.
2. Not all of the ways of assessing a lump mentioned above are needed in
every lymph node examination.Therefore, cater your examination to the
individual.

WEEK 2: PATIENT INTERVIEW

Learning Outcomes:

At the end of the session, students should be able to:

1. Interview a patient presenting with haematological symptoms


2. Elicit a comprehensive family history from a patient
3. Summarise the history taken
4. Identify the problem(s) and demonstrate basic clinical reasoning
5. Generate a case presentation

Good to know about the following haematological diseases

Selected Inherited Blood Disorders


Red cell disorders:
• Disorders of the membrane – hereditary spherocytosis and elliptocytosis
• Disorders of haemoglobin – sickle cell anaemia and thalassaemia
• Disorders of metabolism – pyruvate kinase and glucose 6-phosphate
deficiencies

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Coagulation disorders:
• Factor deficiency – haemophilia A and B
• Combined factor and platelet deficiency – von Willebrand’s disease
• Platelet dysfunction – Bernard-Soulier syndrome (rare)

White cell disorders:


rare functional disorders such as chronic granulomatous disease
Taken from Chamberlain’s Symptoms and Signs in Clinical Medicine – An Introduction to
Medical Diagnosis. 13th Edition. Chapter 17 The Haematological System, page 290

Reference:

You are strongly advised to read the following chapters to help you understand the
important points within each component of history taking for within the
haematological system.

• Clinical Examination: A Systemic Guide to Physical Diagnosis. 7th Edition.


Nicholas J. Talley and Simon O’Connor. Section 6 The Haematological System

• Haematology – An Illustrated Colour Text. 4th Edition. Martin R. Howard and


Peter J. Hamilton. Section 2 Chapter 7 – History Taking

• Chamberlain’s Symptoms and Signs in Clinical Medicine – An Introduction to


Medical Diagnosis. 13th Edition. Chapter 17 The Haematological System

Common haematological abnormalities and associated symptoms

Nature of abnormality Commonly associated symptoms

Anaemia Fatigue, weakness, dyspnea, palpitations,


headache, dizziness, tinnitus

Leucopenia (Particularly Unusually severe or recurrent infections


neutropenia)

Thrombocytopenia Easy bruising, excessive bleeding after trauma,


spontaneous bleeding from mucous membranes

Defective coagulation (e.g. Excessive bleeding after trauma, spontaneous


key factor deficiency) bleeds into joints and muscles

Infiltration by malignancy ‘Lumps’ caused by lymphadenopathy, pain,


(e.g. leukaemia, lymphoma) neurological symptoms
Taken from Haematology – An Illustrated Colour Text. 4th Edition. Martin R. Howard and Peter
J. Hamilton. Section 2 Chapter 7 – History Taking, page 14

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WEEK 3: VENEPUNCTURE

Learning outcomes:

On completion of this session students will be able to:

5. To communicate effectively with patients while carrying out an invasive


procedure
6. To safely and effectively carry out venepuncture on a mannequin

Venepuncture procedure: (Please watch this link)

https://youtu.be/RKuUPO6NNcU

Reference

Essential Clinical Procedures. 3rd Edition. Richard W. Dehn. Chapter 2 Standard


Precautions. Chapter 5 Venipuncture.

Procedure
• Check the patient’s identification ( at least 2 id’s) to ensure that the correct
patient is having the procedure

• Talk to the patient and get an informed consent

• Know the samples you need to collect and identify the right evacuated tubes
with the amount of blood samples needed for each

• Organize your equipment and place them in a tray to take with you

• Label the tubes

• Wash your hands

• Wear your gloves

• Inspect the patient’s surface anatomy for suitable veins and observe for any of
the contraindications mentioned above

• Apply the tourniquet 5-10cm proximal for better visualization of the veins
(NEVER leave tourniquet on for more than 2 minutes)

• Disinfect selected site starting from the centre and work in circular movement
outwards. Allow time to dry. Do NOT touch the cleaned site.

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• Assemble the needle and syringe

• Insert needle, puncturing the skin with the bevel facing UPWARDS with a 15-30
degree angle (depending on how superficial the vein is).

• If using a syringe system, to gently aspirate the amount of blood required. If


using a vacutainer system, to insert the evacuated tube inside the barrel
according to the order of draw.

• Once collected sufficient amount of blood, have your gauze pad ready.
Remove the tourniquet then carefully remove the needle from the skin and
cover the punctured site with the gauze. Apply firm pressure for about 3-4
minutes. ( You can instruct your patient to apply firm pressure with gauze too)

• Transfer the blood into the correct tube.

• Immediately discard used needle into the sharps collecting bin.

• Recheck the venepunture site before you dress the site with bandage or
adhesive strips.

• Clean any blood spillages.

• Remove your gloves, dispose them into clinical waste bin and wash your hands.

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WEEK 4: PUTTING ALL TOGETHER

Learning Outcomes:

At the end of the session, the students should be able to:

1. Reinforce clinical reasoning


2. Learn to develop a list of differential diagnosis
3. Summarise the history taken

You will be given two case scenarios whereby you will practise your history taking
skills as well as connecting the information received in the history to the physical
findings in the examination. From there, you will learn to form a relevant and concise
summary of the case. You will also learn to generate a list of differential diagnoses of
the cases seen. You will be expected to present the cases in the large group for
discussion purposes. Please revise some common haematological diseases
(Haemophilia/ Von Wilibrand disease/ Nutritional deficiency anaemia/Thalassemia/
ITP before attending this class.

Some sample scenarios for you to brainstorm further:

Scenario 1
You are currently posted to the outpatient clinic. A 16-year-old teenager complains
of having gum bleeding for 2 days. Interview him regarding his problem and arrive at
your most likely diagnosis.

Scenario 2
You are in the medical ward now. A 50-year-old lady has been admitted for feeling
tired for the past 2 months.She has a history of chronic renal disease for 10
years.Gather relevant information about her problem and summarise your findings.

Scenario 3
You are posted to the haematology clinic. A 55-year-old retired school teacher
complains of having a swelling on the right side of his neck. Interview him and
perform relevant physical examination on this patient.

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Glossary of important Malay words

Symptoms Translation into Malay words

Fatigue Letih

Weakness Lemah

Dyspnoea Susah nafas

Palpitations Jantung berdebar-debar

Headache Sakit kepala

Dizziness Pening

Tinnitus Bunyi di dalam telinga

Numbness Kebas

Bruising Lebam

Excessive bleeding after trauma Banyak berdarah selepas trauma

Spontaneous bleeding into Pendarahan secara spontan-


joints/muscles sendi/otot
Joint pain/ muscle pain
Sakit sendi-sendi / otot

Lumps Ketulan

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