Symptoms and Pathologies in Haematological System Examination

Examination of the Examination of the Haematological System Haematological System Dr Maria Darko

Symptoms Symptoms Symptoms of anaemia Recurrent infection Prolonged bleeding Bone pain Abdominal distension

Anaemia Anaemia Patients with anaemia from any cause are likely to present with the non-specific symptoms of anaemia. The age and sex of the patient are highly relevant, because inherited disorders of the blood such as sickle cell disease are most likely to present in childhood. In women of childbearing age, by far the most common cause of anaemia is iron deficiency consequent to menstrual blood loss and pregnancy. In contrast, older women and males of any age with iron deficiency should undergo investigation aimed at detecting gastrointestinal blood loss.

Anaemia Anaemia - - Symptoms Symptoms Decreased oxygen transport - Fatigue - Syncope - Dyspnoea - Angina - chest pain Reduced blood volume - Pallor - Postural hypotension Increased cardiac output - Pounding in ears - Palpitations

Anaemia Anaemia - - Symptoms Symptoms Congestive cardiac failure - Orthopnoea - Paroxysmal nocturnal dyspnoea - Tachycardia - Raised central venous pressure - Displaced apex beat - Gallop rhythm on auscultation - Basal crackles on auscultation - Bilateral ankle oedema

Underlying Pathologies Underlying Pathologies The patient may describe symptoms that suggest certain underlying pathologies. For instance, drenching night sweats might indicate lymphoma Bone pain points towards leukaemia , myeloma or metastatic cancer. The past medical history may reveal important clues, such as a history of peptic ulcer disease, malignancy or autoimmune disease. Drug History - Aspirin or other non-steroidal anti-inflammatory drugs may cause occult blood loss from gastritis. Steroid therapy can result in peptic ulceration leading to GI blood loss.

Systemic enquiry Systemic enquiry Systematic questioning may reveal symptoms suggestive of an underlying disease that is causing the anaemia. A history of weight loss, dysphagia, dyspepsia, chronic diarrhoea, change in bowel habit or rectal bleeding should warrant appropriate investigations directed at the GI tract. This is to look for malignancies, peptic ulcer disease, malabsorption states, colitis, haemorrhoids and other causes of GI blood loss.

Systemic Enquiry Systemic Enquiry Similarly, a detailed genitourinary history should be taken in women, with particular emphasis on the extent of menstrual blood loss. In many women of childbearing age, iron losses of menstruation or pregnancy frequently precipitate anaemia. When haematuria is heavy enough to cause anaemia, it is normally the presenting problem itself.

Social History Social History Excess alcohol consumption is associated with Gastritis - can lead to GI bleeding Folate deficiency and Liver disease, with consequent variceal bleeding All these can cause anaemia

Dietary History Dietary History The dietary history is particularly relevant in the assessment of anaemia Nutritional deficiencies of folic acid ,iron and vitamin B12 result in anaemia. Dietary folate deficiency occurs in alcoholics, or when the diet is deficient in green vegetables. There is usually adequate iron in the diet thus iron deficiency is rarely due to poor diet alone. Dietary B12 deficiency is only likely to occur in vegetarians, and is inevitable in strict vegans unless appropriate supplementation is taken, since dietary sources of Vitamin B12 are of animal origin.

Family History Family History A family history of blood disorders (e.g. sickle cell disease, thalassaemia) or autoimmune disorders is relevant. The ethnic origin of the patient is also important. Sickle cell disease is found in the Afro Caribbean. -thalassaemia is commonest in the Mediterranean and in the Indian subcontinent. Prolonged residence in or travel to tropical countries may suggest malaria or other parasitic infestation.

Examination Examination Certain physical signs are likely to be found in patients suffering from anaemia irrespective of the cause . Pallor is best detected by examination of the mucosae (conjunctival or intraoral), although this is a very unreliable guide to an individual's haemoglobin concentration. Specific causes of anaemia are often associated with characteristic physical findings . B12deficiency is one of the few causes of anaemia with peripheral neuropathy It can present with brisk knee reflexes and absent ankle jerks (neuropathy).

Examination Examination The typical facial appearance of poorly treated thalassaemic patients results from the massive expansion of bone marrow that occurs in an attempt to compensate for the anaemia. There s expansion of the facial bones and similar changes result in typical radiological features .

Examination Examination Some physical findings in leukemia and lymphoma include The overgrowth of gingival mucosa that occurs in monocytic leukemias The features of meningism (photophobia, headache, stiff neck) that result from meningeal infiltration by malignant cells.

Examination Examination Anaemia associated with jaundice may indicate haemolysis. Many haemolytic anaemias are associated with skin ulceration Signs of arthropathy indicate connective tissue disease. Examination of the breasts, chest or prostate may suggest carcinoma, which can sometimes present with anaemia.

Examination Examination Enlargement of the liver, spleen and lymph nodes commonly occurs in haematological diseases GI pathology is indicated by Epigastric tenderness Abdominal masses Hemorrhoids Rectal mucosal lesion.

Examination of the Lymph Nodes Examination of the Lymph Nodes The following points should be considered on examination of the lymph nodes: How many nodes are palpable? What is the size of the nodes? What is their consistency? Are they discrete or confluent? Are they mobile or fixed? Is the skin in the vicinity of the lymph nodes abnormal?

The lymph nodes: clinical examination The lymph nodes: clinical examination.

Examination Examination Infections tend to result in tender lymphadenopathy Neoplastic lymph nodes are generally painless. Both TB and HIV infection can cause painless lymph node enlargement. Generalized lymphadenopathy occurs in systemic infections and as a reactive process in skin diseases such as psoriasis or eczema (dermatopathic lymphadenopathy). Inguinal lymphadenopathy commonly occurs in normal people owing to current or past infections affecting the lower limb.

Examination Examination Submandibular LN Axillary Upper limb infections Breast infections (e.g. mastitis, abscess) Dental infections Aphthous ulceration Upper cervical lymph nodes Tonsillitis TB

Examination Examination Generalized lymphadenopathy - Often predominantly cervical and occipital Inguinal Lower limb infections e.g. leg ulcers Genital infection e.g. LGV, genital herpes EBV infection (glandular fever) Cytomegalovirus HIV Toxoplasmosis

Examination Examination Marked, asymmetric or generalized enlargement of lymph nodes suggests lymphoma This should be confirmed by excision biopsy. Lymphadenopathy caused by lymphoma tends to be 'rubbery' in consistency, whereas nodes infiltrated by metastatic carcinoma tend to be firm. The finding of regional lymphadenopathy should always prompt examination of the areas drained by those nodes (e.g. breasts, chest) This is to search for evidence of malignancy.

Hepatosplenomegaly Hepatosplenomegaly Haematological disorders frequently cause enlargement of liver and spleen Palpation should begin in the iliac fossae so that massive hepatosplenomegaly is not missed. Sometimes, they are palpable only on inspiration, and this should also be noted. Some disorders are associated with massive splenic enlargement Some causes of hepatosplenomegaly Myeloproliferative disorders Lymphoproliferative disorders Congestive cardiac failure

Causes of Splenomegaly Causes of Splenomegaly Mild/moderate splenomegaly Autoimmune disease - Sj gren's syndrome, Autoimmune haemolytic anaemia Globin disorders - Thalassaemia, sickle cell dx Infections - TB , EBV ,Brucellosis Malignant disease - Leukaemias Lymphomas Massive splenomegaly( > 10cm ) Infections - Visceral leishmaniasis (kala-azar) ,Malaria (tropical splenomegaly syndrome) Malignant disease - Chronic myeloid leukaemia ,Splenic lymphoma Myeloproliferative disease - Myelofibrosis Storage disorders - Gaucher's disease

Haematological cancers Haematological cancers These are broadly split into two major types: Acute and chronic. The acute forms are generally abrupt in onset They're often with marked physical signs and laboratory features. These diseases are aggressive in character and rapidly fatal unless treated promptly.

Haematological Cancers Haematological Cancers Chronic malignancies have often been present for many months before diagnosis There are relatively few symptoms and signs These disorders are less aggressive and patients do not require treatment immediately. A large proportion of the acute haematological malignancies can be cured with treatment. Most of the chronic forms cannot be cured They can usually be controlled with treatment, but not eliminated completely.

Chronic Haematological Malignancies Chronic Haematological Malignancies Chronic leukaemias and lymphomas affect older individuals predominantly. Because of the very slow growth of these disorders, patients may not notice any change in their general health. Weight loss, sweating and other constitutional symptoms may occur, but are often less severe than in the acute disorders. Infection and anaemia occur but are generally less than in the acute diseases. Marked lymphadenopathy occurs, and enlargement of the liver and spleen is quite common.

Coagulation Disorders Coagulation Disorders

Introduction Introduction Disorders of primary haemostasis, which generally result from defects in platelet function or number, result in petechiae and bleeding from mucosal surfaces. Disorders of secondary haemostasis (as exemplified by haemophilia) usually result in haemorrhage into deeper structures such as muscles and joints.

Introduction Introduction It is important to take a 'bleeding history' that will discriminate easy bruising from a potentially important haemorrhagic disorder An important aspect of the history will be the duration of any bleeding tendency. An increased bleeding tendency from birth suggests an inherited disorder, whereas a later onset suggests an acquired disorder.

History History The presence of a clotting defect is suggested by frequent and persistent blood loss, often after minimal injury. Blood loss is often overestimated by a third party (e.g. the concerned mother of a child who has bled after dental extraction), so it is useful to try to obtain some objective evidence of excessive blood loss. Any history of prior dental extraction, circumcision, surgery or vaginal delivery should be obtained, as these are all significant challenges to the clotting system, and if excess bleeding did not occur then a major clotting disorder is unlikely.

History History Features suggestive of a haemostatic defect include the requirement for blood transfusion or for surgical intervention to stop bleeding. A history of spontaneous bleeding, excessive post- circumcision bleeding or of bleeding into muscles or joints after only minimal trauma, is highly suggestive of haemophilia. Excessive bleeding from the umbilical stump after separation of the cord is characteristic of factor XIII deficiency.

Drug History Drug History Certain drugs affect the coagulation system, most obviously the anticoagulants warfarin and heparin. Sometimes patients will not spontaneously report drug intake because the preparation was bought 'over the counter'. An example of such an over the counter drug is Aspirin : platelet function is deranged for up to 3 weeks after a single dose of the drug.

Examination Examination The first element of the examination is to observe the character of any bruising or haematoma. Bruising due to abnormal platelet function or number most often results in purpura - tiny pinprick bruises due to haemorrhage from small cutaneous vessels. When compressed, purpura does not blanch, unlike similar cutaneous lesions resulting from small vessel inflammation, which will blanch on pressure. When severe, platelet abnormalities may result in retinal haemorrhage. Ophthalmoscopic examination is mandatory in anyone with evidence of widespread purpura and mucosal haemorrhage.

Differential Diagnosis Differential Diagnosis Thrombocytopenia has a wide-ranging differential diagnosis that overlaps with that of anaemia. A detailed general physical examination may provide diagnostic clues. Some differential diagnosis include TAR syndrome Leukemia Lymphoma

Investigation of bleeding Disorder Investigation of bleeding Disorder FBC - thrombocytopenia Blood film Confirms thrombocytopenia, platelet size, structure, colour, other abnormalities e.g. leukaemia Prothrombin time/INR tests the extrinsic pathway of the clotting cascade Thrombin time Tests fibrin formation Activated partial thromboplastin time Tests the intrinsic pathway of the clotting cascade.

Causes of an abnormal PT/INR Causes of an abnormal PT/INR Warfarin or heparin therapy Liver disease Malabsorption of vitamin K Haemorrhagic disease of the newborn Disseminated intravascular coagulation

Causes of an abnormal APTT Causes of an abnormal APTT Haemophilia A or B (factor VIII or IX deficiency, respectively) von Willebrand's disease Warfarin or heparin therapy Liver disease Disseminated intravascular coagulation

Causes of an abnormal TT Causes of an abnormal TT Low fibrinogen levels Abnormal fibrinogen (dysfibrinogenemia) Heparin Elevated fibrinogen degradation products

Format for Examination Format for Examination Note any bruises on the skin or petechiae Pallor Jaundice Check for lymph nodes Check for swellings under the skin Palpate for bone pain Examine the abdomen for the spleen and liver enlargement.

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