Haematological Examination Full Notes for Medical Students

HAEMATOLOGICAL  EXAMINATION NOTES

• Introduction, Wash Hands, Consent,
• General Inspection:
  • Wasting, Cachexia (Malignancy)

• • Mediterranian Origin & Frontal Bossing (Thallassaemias)
  • African Origin (Sickle Cell Anaemias)
  • Gross Pallor (Anaemia & All Haem Malignancies)
  • Jaundice & Scratch Marks (Haemolytic Anaemia)
  • Cyanosis
  • Facial Plethora (Polycythaemia, SVC obstruction from Lymphoma)
  • Bruising, Bleeding, Petechiae, Purpura (Thrombocytopaenia, Haemophilia & All Haem Malignancies)
  • Neck Swellings (Lymphoma & All Haem Malignancies)
  • Abdominal Distension (Organomegaly due to Infection & All Haem Malignancies)
• Vital Signs:
  • Pulse:
    • Tachycardia (Infection, Anaemia)
  • Blood Pressure:
    • Postural Hypotension (Anaemia)
  • Respiratory Rate:
    • Tachypnoea (Anaemia)
  • Temperature:
    • Fever (Malignancy, Infection)
• Hands:
  • Warm/Well Perfused + CRT
  • Palmar Crease Pallor (Anaemia)
  • Peripheral Cyanosis
  • Koilonychia (Spoon Nails) and Pale Nails (Iron Deficiency Anaemia)

• • Palmar Erythema (Polycythaemia, Chronic Leukaemias)
  • Blue Lunulae (Wilson’s Disease)

• • Digital Infarcts & Raynaud’s (Rheumatoid, Multiple Myeloma)
  • Arthropathy (Rheumatoid, Connective Tissue Disease, Haemophilia)
  • Gouty Tophi (↑Cell Turnover in Malignancy, Myeloproliferative Diseases & Hb Disorders)
  • Dupuytren’s Contracture (B12 Deficiency, Alcoholism & Megaloblastic Anaemia)
• Arms:
  • Bruising, Petechiae, Purpura (Haemophilia, Thrombocytopaenia & All Haem Malignancies)

• • Scratch Marks (Jaundice – Haemolytic Anaemia)
  • Epitrochlear & Axillary Lymph Nodes (All Haem Malignancies)
    • Supraclavicular, Infraclavicular, Parasternal, Subpectoral, Subscapular, Central, Lateral
• Face:
  • Conjunctival Pallor, Angular Stomatitis, Atrophic Glossitis (Anaemia)

■

• • Scleral Icterus
  • Central/Peripheral Cyanosis
  • Facial Plethora (Polycythaemia)
  • Pemberton’s Sign (SVC Obstruction due to Lymphoma)

• • Buccal Petechiae (Thrombocytopaenia, Haemophilia, Bleeding Disorders & All Haem Malignancies)
  • Candidal Mouth Infections (All Haem Malignancies)
  • Gum Hypertrophy + Bleeding (AML – Acute Myeloid Leukaemias)

• • Gum Hypertrophy (Methotrexate Chemotherapy)
  • Enlarged Tonsils (MALT Lymphoma)
  • Wasting (All Haem Malignancies)
• Neck:
  • Cervical Lymph Nodes (Submenta/Submandibular/Pre/Post-Auricular/Occipital/Jugular/Post-Triangl) (In All Haem Malignancies)
    • Firm, Non-Tender, Immobile = Malignancy
    • Tender, Mobile = Infection
    • Site
    • Size (>1cm)
    • Consistency (Hard – Carcinoma; Rubbery – Lymphoma)
    • Tenderness (Infection)
    • Mobility (Fixed if Malignant)
  • Neck Swellings/Masses
  • **Check for Dysphagia/Odynophagia (Plummer Vinson Oesophageal Web from Iron def. Anaemia)
  • Thyroid Examination (As Hypothyroidism can ➔ menorrhagia ➔ anaemia)
  • BCC/SCCs from Immunosuppression (Chemotherapy)
  • Radiotherapy Tattoos
• Chest:
  • Bruising, Petechiae, Purpura (Bleeding Disorders, Haemophilia, Thrombocytopaenia & All Haem Malignancies)
  • Chest Infections (Immunosuppression)
  • Systolic Flow Murmur (Severe Anaemia)
  • ***Bony Tenderness (ALL Haematological Malignancies) – Ribs, Clavicles, Spine, Hips.
• Abdomen:
  • Bruising, Petechiae, Purpura (Bleeding Disorders, Haemophilia, Thrombocytopaenia & All Haem Malignancies)
  • Hepatomegaly, Splenomegaly (All Haem Malignancies)
  • Para-Aortic Lymph Nodes
  • Ascites
  • Per Rectal Examination – Blood on Stool
  • Palpate Kidneys (Signs of Renal Failure ➔ Anaemia of Chronic Disease)
• Inguinal:
  • Inguinal Lymph Nodes (All Haem Malignancies)
  • Testicular Masses in Children (ALL – Acute Lymphoblastic Leukaemia)
  • DRE (Lymphoma)
• Legs:
  • Bruising, Petechiae, Purpura (Bleeding Disorders, Haemophilia, Thrombocytopaenia & All Haem Malignancies)
  • Scratch Marks (Haemolytic Jaundice)
• Feet:
  • Peripheral Perfusion & CRT
  • Koilonychia & Pale Nails (Iron Deficiency Anaemia)
  • Sole Erythema (Polycythaemia)
  • Gouty Tophi (↑Cell Turnover in Myeloproliferative Diseases & Hb Disorders)

• Thank patient “that concludes my examination”, I’ll go organise further tests.

Focussed Anaemia Examination:

• Introduction, Wash Hands, Consent,
• General Inspection:
  • Alert & Oriented
  • Racial Origin (African = Sickle Cell Anaemia; Mediterranean = Thallassemia)
  • Gross Pallor (Anaemia), Jaundice (Haemolytic Anaemia), or Cyanosis.
  • Scratch Marks (Jaundice from Haemolytic Anaemia)
  • Bruising, Petechiae, Purpura (Thrombocytopaenia any Haem Malignancies)
• Vital Signs:
  • Pulse:
    • Tachycardia
  • Blood Pressure:
    • Postural Hypotension
  • Respiratory Rate:
    • Tachypnoea
  • Temperature:
    • Normal
• Hands:
  • Warm & Well Perfused + CRT
  • Koilonychia (Iron Deficiency Anaemia)
  • Pale Nails (General Anaemia)
  • Leukonychia (Chronic Kidney Disease ➔ Hypoalbuminaemia)
  • Palmar Crease Pallor
  • Dupuytren’s Contracture (Megaloblastic Anaemia from Alcoholism)
• Arms:
  • Bruising/Petechiae/Purpura (Thrombocytopaenia due to Myelosuppression which also ➔ Anaemia)
  • Scratch Marks (Haemolytic Jaundice ➔ Anaemia)
• Face:
  • Conjunctival Pallor
  • Scleral Icteris (Haemolytic)
  • Central/Peripheral Cyanosis
  • Angular Stomatitis (General Anaemia)
  • Atrophic Glossitis (General Anaemia)
  • Gum Bleeding (AML ➔ As a cause of Iron Deficiency Anaemia)
  • Buccal Petechiae/Purpura (Thrombocytopaenia due to Myelosuppression which also ➔ Anaemia)
• Neck:
  • Cervical Lymphadenopathy (Because All Haem Malignancies cause Anaemia)
  • **Check for Dysphagia/Odynophagia (Plummer Vinson Oesophageal Web from Iron def. Anaemia)
  • Thyroid Examination (As Hypothyroidism can ➔ menorrhagia)
• Chest:
  • Bony Tenderness (All Haem Malignancies)
  • Systolic Flow Murmurs (hyperdynamic circulation)
• Abdomen:
  • Cullen’s/Grey Turner’s Signs of Haemoperitoneum (Haemorrhagic Anaemia)
  • Tenderness (Peptic Ulcer Disease, Crohns, Ulcerative Colitis)
  • Hepatomegaly & Splenomegaly (All Haem Malignancies cause Anaemia)
  • Per Rectal Examination – Blood on Stool
  • Palpate Kidneys (Signs of Renal Failure ➔ Anaemia of Chronic Disease)
• Legs:
  • Peripheral Perfusion
• Feet:
  • Peripheral Perfusion + CRT
  • Koilonychia (Iron def Anaemia)
  • Pale Nails (General Anaemia)
• Thank patient “that concludes my examination”, I’ll go organise further tests.

Focussed Leukaemia Examination:

• Introduction, Wash Hands, Consent,
• General Inspection:
  • Alert & Orientated?
  • Wasting, Weight Loss
  • Gross Pallor (Marrow Overcrowding – All Haem Malignancies)
  • Lethargy
  • Obvious masses (Neck/Abdomen)
  • Bruising, Bleeding, Petechiae, Purpura (Thrombocytopaenia – All Haem Malignancies)
• Vital Signs:
  • Pulse:
    • Normal
    • Tachycardia (If Anaemia)
  • Blood Pressure:
    • Normal
    • Postural Hypotension (if Anaemia)
  • Respiratory Rate:
    • Normal
    • Tachypnoea (If Anaemia)
  • Temperature:
    • Febrile (All Haem Malignancies, Infection)
• Hands:
  • Peripheral Perfusion + CRT
  • Pale Nails & Palmar Crease Pallor (Marrow Overcrowding Anaemia)
  • Palmar Erythema (Chronic Leukaemias)
  • Gouty Tophi (High Turnover in Myeloproliferative)
• Arms:
  • Bruising, Petechiae, Purpura (Marrow Overcrowding Thrombocytopaemia)
  • Epitrochlear & Axillary Lymp Nodes (All Haem Malignancies)
    • Supraclavicular, Infraclavicular, Parasternal, Subpectoral, Subscapular, Central, Lateral
• Face:
  • Gross/Conjunctival Pallor (Marrow Overcrowding Anaemia)
  • Central/Peripheral Cyanosis
  • Gum Hypertrophy & Bleeding (Acute Myeloid Leukaemia)
  • Gum Hypertrophy (Methotrexate Side Effect)
  • Candidal Mouth Infections (Neutropaenia – All Haem Malignancies)
• Neck:
  • Cervical Lymphadenopathy (All Haem Malignancies)
  • Meningism (Due to CNS Infiltration – esp. ALL)
• Chest:
  • Bruising, Petechiae, Purpura (Thrombocytopaenia)
  • Bony Tenderness (Bony Infiltration – All Haem Malignancies)
  • Chest Infections (Immunocompromise – From Chemo or Neutropaenia)
• Abdomen:
  • Bruising, Petechiae, Purpura (Thrombocytopaenia – All Haem Malignancies)
  • Distension
  • Hepatomegaly, Splenomegaly (All Haem Malignancies)
  • Para-Aortic Lymph Nodes
• Legs:
  • Inguinal lymph Nodes
  • Testicular Masses (Acute Lymphoblastic Leukaemia)
  • Bruising, Petechiae, Purpura (Thrombocytopaenia – All Haem Malignancies)
• Feet:
  • Peripheral Perfusion + CRT
  • Pale Nails (Anaemia)
• Thank patient “that concludes my examination”, I’ll go organise further tests.

Focussed Lymphoma Examination:

• Introduction, Wash Hands, Consent,
• General Inspection:
  • Alert & Orientated
  • Wasting, Weight Loss
  • Neck Swellings
  • Facial Plethora (SVC Obstruction)
  • Gross Pallor (Marrow Infiltration)
  • Bruising, Petechiae, Purpura (Marrow Infiltration)
• Vital Signs:
  • Pulse:
    • Normal
    • Tachycardia (if Anaemia due to BM Infiltration)
  • Blood Pressure:
    • Normal
    • Postural Hypotension (if Anaemia due to BM Infiltration)
  • Respiratory Rate:
    • Normal
    • Tachypnoea (If Anaemia due to BM Infiltration)
  • Temperature:
    • Fever
• Hands:
  • Peripheral Perfusion + CRT
  • Peripheral Cyanosis
  • Palmar Crease Pallor (Anaemia of BM Infiltration)
  • Pale Nails (Anaemia of BM Infiltration)
  • Scratch Marks (Pruritis of Lymphoma)
• Arms:
  • Epitrochlear Lymph Nodes (All Haem Malignancies)
  • Axillary Lymph Nodes (Supra/Infraclavicular/Parasternal/Pectoral/Subscapular/Central/Lateral)
    • *Painful
• Face:
  • Conjunctival Pallor (Anaemia of BM Infiltration)
  • Scleral Icteris
  • Wasting
  • Central/Peripheral Cyanosis
  • Enlarged Tonsils (MALT Lymphoma)
  • Candidal Mouth Infections (Immunocompromise – All Haem Malignancies)
• Neck:
  • Painful Cervical Lymphadenopathy (All Areas)
• Chest:
  • Chest Infections (Immunocompromise – All Haem Malignancies)
  • Systolic Flow Murmurs (if Anaemia of BM Infiltration)
  • Bony Tenderness (Bony Infiltration – All Haem Malignancies)
• Abdomen:
  • Hepatomegaly (All Haem Malignancies)
  • Splenomegaly (All Haem Malignancies)
  • Para-Aortic Lymphadenopathy
  • Abdominal Masses (MALT Lymphoma)
  • Bruising, Petechiae, Purpura (Thrombocytopaenia of BM Infiltration)
• Legs:
  • Bruising, Petechiae, Purpura (Thrombocytopaenia of BM Infiltration)
• Feet:
  • Peripheral Perfusion + CRT
  • Fungal Nail Infections (Pancytopaenia of BM Infiltration)
• Thank patient “that concludes my examination”, I’ll go organise further tests.

Focussed Multiple Myeloma Examination:

• Introduction, Wash Hands, Consent,
• General Inspection:
  • Wasting, Weight Loss
  • Pallor (Anaemia of BM Infiltration)
  • Bruising, Petechiae, Purpura (Thrombocytopaenia of BM Infiltration)
  • Abdominal Masses (Hepatomegaly +/- Splenomegaly)
• Vital Signs:
  • Pulse:
    • Tachycardia (Anaemia of BM Inifiltration)
  • Blood Pressure:
    • Postural Hypotension (Anaemia of BM Inifiltration)
  • Respiratory Rate:
    • Tachypnoea (Anaemia of BM Inifiltration)
  • Temperature:
    • Fever (Due to Infection/Malignancy)
• Hands:
  • Peripheral Perfusion + CRT
  • Raynaud’s Phenomenon & Digital Infarcts (Blood Hyperviscosity)
  • Palmar Crease Pallor & Pale Nails (Anaemia of BM Inifiltration)
• Arms:
  • Bruising, Petechia, Purpura (BM Infiltration ➔ Thrombocytopaenia)
  • Epitrochlear Lymphadenopathy (All Haem Malignancies)
  • Axillary Lymphadenopathy (All Haem Malignancies)
• Face:
  • Conjunctival Pallor
  • No Central or Peripheral Cyanosis
  • Mucosal Candida Infections (Immunocompromise & Neutropaenia)
• Neck:
  • Cervical Lymphadenopathy (All Haem Malignancies)
• Chest:
  • BONY TENDERNESS (Especially in Ribs & Lumbar Spine)
  • Bruising, Petechiae, Purpura (BM infiltration ➔ Thrombocytopaenia)
• Abdomen:
  • Bruising, Petechiae, Purpura (BM infiltration ➔ Thrombocytopaenia)
  • Massive Hepatomegaly +/- Splenomegaly
  • Signs of Renal Failure (Due to Ig-Deposition in Kidneys) ➔ Ascites, Uraemic Fetor, etc
• Legs:
  • Peripheral Neuropathy (Due to Spinal Cord Compression)
  • Bruising, Petechiae, Purpura (BM infiltration ➔ Thrombocytopaenia)
  • Oedema (If Renal Failure)
• Feet:
  • Peripheral Perfusion + CRT
  • Peripheral Neuropathy (Due to Spinal Cord Compression)
  • Fungal Nail Infections (Immunocompromise)
• Thank patient “that concludes my examination”, I’ll go organise further tests.

 

Thank You so Much. Happy Learning!!