Usefull for educational purposes hematology history taking clinic rounds medical student education

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History Taking and Physical Examination
of the Hematopoietic System
Asst. Prof. Aşkın K. KAPLAN, M.D.
Maltepe University
Maltepe Faculty of Medicine

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Assessment of a Patient in Hematology
• Medical history taking
• Physical examination

3. 3
Medical History Taking

4. 4
Medical History
• Determine the nature of the illness
• Identify patient’s symptoms systematically
– Obtain as much relevant information as possible
about their origin and evolution and about the
general health of the patient by appropriate
questions
A good doctor had to be able not simply to ask the right
questions, but also to look for the right answers

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Medical History
• Medical history taking
– Assessment of symptoms
– Reviewing previous records
• Understanding the onset or progression of illness
– Personal medical history for other disorders that can
cause blood count abnormalities
• Hematologic manifestations secondary to other diseases occur
more frequently than primary hematologic diseases
– Person’s ethnicity or race
– Exposures; drugs, chemicals, toxins, radiation, alcohol
– Family history

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The History- General Symptoms & Signs
• Performance status
• Weight loss
– is a frequent accompaniment of many serious diseases,
including primary hematologic malignancies, but it is
not a prominent accompaniment of most hematologic
diseases.
• Fever
– Pyrogenic cytokines (e.g., interleukin [IL]-1, IL-6, and IL-
8) in aggressive lymphoma, acute leukemia, primary
myelofibrosis, severe hemolytic anemia
– Neutropenia
• Night sweats

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Performance Status- Karnofsky Scale
• Establish semiquantitatively the extent of a patient’s
disability
Able to carry on normal activity; no special care is needed.
100% Normal; no complaints, no evidence of disease
90% Able to carry on normal activity; minor signs or symptoms of disease
80% Normal activity with effort; some signs or symptoms of disease
Unable to work; able to live at home, care for most personal needs; a varying amount
of assistance is needed.
70% Cares for self; unable to carry on normal activity or to do active work
60% Requires occasional assistance but is able to care for most personal needs
50% Requires considerable assistance and frequent medical care
Unable to care for self; requires equivalent of institutional or hospital care; disease
may be progressing rapidly.
40% Disabled; requires special care and assistance
30% Severely disabled; hospitalization is indicated though death not imminent
20% Very sick; hospitalization necessary; active supportive treatment necessary
10% Moribund; fatal processes progressing rapidly
0% Dead

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Eastern Cooperative Oncology Group (ECOG)
Performance Status
Grade Activity
0 Fully active, able to carry on all predisease performance without
restriction
1 Restricted in physically strenuous activity but ambulatory and able to
carry out work of a light or sedentary nature
2 Ambulatory and capable of all self-care but unable to carry out any
work activities; up and about more than 50% of waking hours
3 Capable of only limited self-care, confined to bed or chair more than
50% of waking hours
4 Completely disabled; cannot carry on any self-care; totally confined to
bed or chair
5 Dead

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• Fatigue, malaise, and lassitude
– Anemia
– Malignancies
The History- General Symptoms & Signs

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• Weakness; general loss of strength or reduced
capacity for exercise
– Anemia
– Wasting of malignant processes
– Neurologic complications of hematologic disease;
• vitamin B12 deficiency
• monoclonal immunoglobulinemias
• Central or peripheral nervous system invasion or compression as
a result of vertebral collapse, a paraneoplastic syndrome (e.g.,
encephalitis), or brain or meningeal involvement.
• Myopathy secondary to malignancy; usually manifest as
weakness of proximal muscle groups.
• Foot drop or wrist drop; lead poisoning, amyloidosis, systemic
autoimmune diseases, or vincristine therapy
• Paralysis may occur in acute intermittent porphyria.
The History- General Symptoms & Signs

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The History- Spesific Symptoms or Signs
• Headache
• Paresthesias
• Confusion
• Impairment of consciousness
Nervous System

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The History- Spesific Symptoms or Signs
• Epistaxis
• Anosmia;
– pernicious anemia, malignancy,
opportunistic infections
• Pain or tingling in the tongue
– Pernicious anemia, iron deficiency,
vitamin deficiency
• Macroglossia
• Bleeding gums
– Bleeding disorders, acute leukemia
• Ulcerations
– Neutropenia
• Dryness
– Hypercalcemia
• Dysphagia
– Iron deficiency anemia
• Painless swelling in the neck
– Lymphadenopathy
– Superior vena cava obstruction
Head & Neck
• Conjunctical pallor, plethora
• Blindness;retinal hemorrhages
• Blurred vision; hyperviscosity
• Complete or partial visual loss;
retinal vein or artery thrombosis
• Diplopia
• Disturbances of ocular
movement
– Paralysis of the 3rd, 4th, or 6th
cranial nerves
• Vertigo, tinnitus, roaring in the
ears
– Anemia, polycytemia

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Chest & Heart
• Dyspnea
• Palpitations
• Congestive heart failure
• Angina pectoris
• Cough
– Enlarged mediastinal nodes
• Chest pain
– Involvement of the ribs or sternum
with lymphoma or multiple myeloma
– Nerve root invasion or compression
– Herpes zoster
– Pulmonary infarct
• Hemoptysis
• Tenderness of the sternum
– Leukemias
– Primary myelofibrosis
– Lymphoma, myeloma
Gastrointestinal System
• Dysphagia
• Anorexia
• Indigestion
• Abdominal fullness
• Premature satiety
– Splenomegaly
• Abdominal pain
– Obstruction, retroperitoneal bleeding,
lead poisoning, ileus, acute hemolysis,
sickle cell disease, acute intermittent
porphyria
• Diarrhea
– Malabsorption
• Gastrointestinal bleeding
• Constipation
– Hypercalcemia
– Vinca alkaloids
The History- Spesific Symptoms or Signs

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Genitourinary & Reproductive
System
• Impotence or bladder
dysfunction
– Spinal cord or peripheral nerve
damage
• Priapism
– Leukemia, essential
thrombocytemia, or sickle cell
anemia
• Hematuria
• Red urine; hemoglobinuria
– Intravascular hemolysis,
myoglobinuria, or porphyrinuria
• Amenorrhea
• Menorrhagia
Back & Extremities
• Back pain
• Arthritis
• Arthralgia
• Hemarthroses
• Shoulder pain
• Bone pain
• Edema
The History- Spesific Symptoms or Signs

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Skin
• Dryness
– Iron deficiency
• Nail abnormalities
– Brittles
• Jaundice
• “Lemon yellow” skin
– Pernicious anemia
• Pallor
• Erythromelalgia
– Polycythemia vera, E.
throbocytemia
• Erythroderma, infiltrative lesions
• Cyanosis
– Methemoglobinemia
– Abnormal hemoglobins with high
oxygen affinity
• Itching
– Hodgkin lymphoma, mycosis
fungoides
• Petechiae, purpura, ecchymoses
• Easy bruising
• Leg ulcers
– Sickle cell anemia
The History- Spesific Symptoms or Signs

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The History- Drugs & Chemicals
• Complete history of drug use
• Detailed information on alcohol consumption
from every patient
– Amount, duration..
• Patients should be asked about the use of
recreational drugs.
– The use of “alternative medicines” and herbal
– Nonjudgmental questioning may be successful in
identifying agents in this category

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The History
• Vaccination
– Immune thrombocytopenia
• Nutrition
– Dietary deficiency in anemia
• Sexual history
– HIV infection
• Family History
– Hemoglobinopathies
– Bleeding manifestations
– Venous thromboembolism

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Preventive Hematology
• Identification of individual genetic risk factors
• Avoidance of situations that may make a
latent disorder manifest.
• Prophylactic therapy
– Anticoagulant prophylaxis for venous stasis
• Elimination of sources of environmental
factors
• Prenatal diagnosis

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Physical Examination
• Performance status
• Skin and mucous membranes
• Nervous system
• Head & neck examination
• Lymph node examination
• Abdominal examination for enlargement of the
spleen and liver
• Musculoskeletal system
• Rectal examination if necessary for the
assessment of stool for blood

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Physical Examination- Skin
• The color of the skin
– Pallor; anemia
– Redness; polycythemia
• The mucous membranes and nail beds are
usually more reliable guides to anemia or
polycythemia than the skin
• The palmar creases are useful guides to the
hemoglobin level
• Liver disease may induce flushing of the thenar
and hypothenar eminences of the palm, even in
patients with anemia

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normal soluk

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Physical Examination- Skin
• Cyanosis
– Is a function of the total amount of reduced
hemoglobin, methemoglobin, or sulfhemoglobin
present
– The minimum amounts of these pigments that
cause detectable cyanosis are approximately 5
g/dL blood of reduced hemoglobin, 1.5 to 2.0 g/dL
of methemoglobin, and 0.5 g/dL of
sulfhemoglobin

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Physical Examination- Skin
• Jaundice
– Staining of the skin by bile pigment, and bilirubin
glucuronide
– Jaundice of the skin may not be visible if the
bilirubin level is below 2 to 3 mg/dL

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Physical Examination- Skin
• Petechiae
– Small (1 to 2 mm), round, red or brown lesions
– Present primarily in areas with high venous pressure,
such as the lower extremities
– These lesions do not blanch on pressure
– Palpable petechiae; vasculitis
• Ecchymoses
– May be of various sizes and shapes and may be red,
purple, blue, or yellowish green, depending on the
intensity of the skin hemorrhage and its age

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Bleeding Diathesis- Thrombocytopenia
• May be asymptomatic
• Mucocutaneous bleeding is characteristic

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Physical Examination- Skin
• Excoriation
– Itching; Hodgkin lymphoma
• Leg ulcers
– Sickle cell anemia
– Hereditary anemia
• Nails
– In chronic severe iron- deficiency anemia nails
may be ridged longitudinaly
– Koilonychia; flattened or concave nails

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Physical Examination- Eyes
• Jaundice, pallor, or plethora
• Retinal hemorrhages and exudates
• Dilatation of the veins
– Polycythemia
– Macroglobulinemia

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Physical Examination- Mouth
• Pallor of the mucosa; anemia
• Ulceration; neutropenia
• Swelling of the gums; acute leukemia
• Bleeding from the mucosa
• Dark line of gums; lead poisining
• Smooth and red tongue; pernicious or iron
deficiency anemia
• Macroglossia; primary amyloidosis

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Anemia

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Lymphoid Organs
• Primary lymphoid organs
– Bone marrow
– Thymus
• Secondary lymphoid organs
– Lymph node
– Spleen
– Peyer patches
– Waldeyer ring (tonsils, adenoids)

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Lymph Node Regions in Lymphoma

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Physical Examination- Lymph Nodes
• Palpable lymph node regions
– Suboccipital, auricular, cervical, supraclavicular, axillary,
epitrochlear, inguinal, or iliofemoral, popliteal
• In inguinal area 0.5 to 2.0 cm lymph node can be
found in normal individuals
• 0.5 to 1.0 cm nodes may be palpated in the cervical
region
• Palpation should be gentle and is best performed
with a circular motion of the fingertips, using slowly
increasing pressure
• Tender lymph nodes usually indicate an
inflammatory etiology

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Physical Examination- Chest
• Increased rib or sternal tenderness
• Increased bone pain
– Leukemia, multiple myeloma, metastatic tumors

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Physical Examination
• Spleen
– Masses in the stomach, colon, kidney, or pancreas
may mimic splenomegaly on physical examination
• Liver
– It is necessary to determine both the upper and
lower borders of the liver by percussion in order to
properly assess liver size
– The normal liver may be palpable as much as 4 to 5
cm below the right costal margin

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Physical Examination- Nervous System
• Vitamin B12 deficiency
• Leukemic meningitis
• Brain or spinal cord compression
• Neurologic abnormalities
– Leukemia, lymphoma, myeloma related tumor infiltration,
bleeding, infection, or paraneoplastic syndrome
• Neuropathies
– Monoclonal gammopathy
• Polyneuropathy
– POEMS; polyneuropathy, organomegaly, endocrinopathy,
monoclonal gammopathy, and skin changes

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Physical Examination- Joints
• Hemorrhage in patients with hemophilia

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Neutropenic Fever- Physical
Examination
Site Findings
Lung Hypoxia, tachypnea, shortness of breath
Abdomen Peritoneal signs and/or abdominal tenderness
Even when an abdominal process is present, abdominal signs may
be subtle or absent in neutropenic patients.
Catheter sites Slight erythema or tenderness
Fluctuance or exudates are unlikely since the lack of inflammatory
cells inhibits the development of inflammatory reactions.
Skin/mucous
membranes
Erythema, rash, cellulitis, ulcers, furuncles, vesicles, paronychia,
mucositis, dental or peritonsillar cellulitis, perianal fissures, and
pilonidal disease.
Perianal region Erythema, pain on palpation, and tender hemorrhoids
Digital rectal examination (and rectal temperatures) should be
avoided so that one does not introduce infection by traumatizing
the fragile mucosa.

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Reference
• Williams Hematology, 9th ed 2016, by
McGraw-Hill Education. Marshall A. Lichtman;
Linda J. Burns
– Clinical evaluation of the patient

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Thank You
Asst. Prof. Aşkın K. Kaplan M.D.
askinkkaplan@gmail.com

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History of Present Illness - HPI
• Fatigue anaemia
• Weakness anaemia
• Palpitations anaemia
• Swollen ankles lymphoedema
• Postural dizzyness anaemia
• Bleeding thrombocytopenia or clot disorder
• Bruising thrombocytopenia or clot disorder
• Fever cancer
• Night sweats cancer
• Weight loss cancer
• Jaundice hemolysis or liver dysfunction
• Lymph n enlargement cancer
• Lumps of any sort? cancer
• Bone pain cancer mets
• Tingling and loss of sensation B12 deficit anaemia
• Skin rash lupus / bacyteraemia / cancer / autoimmune hemolytic anaemia