Hematological Examination

Haematological Examination Component What to do/look for and rationale Position the patient in flat position. Mobility aids Comfort and state Muscle wasting Pallor General Inspection Nursing Jaundice Haemolytic anaemia Scratch marks Lymphoma Myeloproliferative disease Koilonychia Brittle, dry, ridged and spoon shaped nails. Severe iron deficiency Fungal infection Raynaud’s phenomenon Digit infarction Abnormal globulins e.g. cryoglobulinemia Pallor of the nail beds Anaemia -> unreliable sign Pallor of the palmar creases Low Hb levels -> unreliable sign. Gouty arthritis Hands May be a manifestation of myeloproliferative disease Rheumatoid arthritis When associated with splenomegaly and neutropenia -> Felty’s syndrome (may be associated with thrombocytopenia, haemolytic anaemia, skin pigmentation and leg ulceration. Signs of connective tissue disease Chronic inflammation -> anaemia Purpura Any sort of bruising due to haemorrhage into the skin. These lesions can be small -> petechia (spot) -> if raised -> palpable purpura -->NOT DUE TO THROMBOCYTOPENIA -> SUGGESTS AN UNDERLYING SYSTEMOC VASCULITIS -> could be painful or bacteraemia. If large in size -> ecchymoses. Pulse Tachycardia -> compensation for anaemia. If thrombocytopenia or capillary fragility is suspected -> Hess test Blood pressure cuff is placed on the patient’s upper arm and inflated to a pressure between the systolic and diastolic pressure. The cuff is left for 5 minutes. After the cuff is removed -> the area below the cuff is examined for petechiae. Forearms Normally: Fewer than 15 petechiae should appear within a 5cm diameter circle on the skin. If more than 15 are present -> increased capillary fragility. Could be due to: Thrombocytopenia. Poor platelet function Other bleeding disorders. Epitrochlear nodes: Ask the patient to flex their elbows as 90 degrees. Ask the patient to abduct the upper arm a little. Place the palm of your right hand under the patient’s elbow. Place the thumb proximal and anterior to the medial condyle. Enlarged lymph node: NHL Syphilis Local infection Axillary lymph nodes: Nodes Ask the patient to raise their arm. Using the left hand palpate the right side. Push your fingers as high as possible into the axilla. Bring the patients arm down to rest to your forearm and ask them to relax and allow you to take the weight. Five main groups of axillary nodes: Central Lateral -> above and lateral Pectoral (medial). Infraclavicular Subscapular (most inferior). Scleral jaundice, haemorrhage or injection. Eyes Conjunctival pallor. Anaemia -> more reliable than examination of the nail bed. Nose Bleed Telangiectasis around the mouth Hereditary haemorrhagic telangiectasis Examine for hypertrophy of the gums: Infiltration by leukemic cells -> esp. acute monocytic anaemia. Gum bleeding Ulcerations Mouth Infections Haemorrhages Atrophic glossitis Megaloblastic anaemia or iron deficiency. Look for enlarged tonsils Waldeyer’s ring: Circle of lymphatic tissue in the posterior part of oropharynx and the nasopharynx as well as the tonsils and the adenoids. NHL but rarely in HL. Sit the patient up. Examine the cervical lymph nodes: Submental -> directly under the chin. Submandibular -> above the angle of the jaw. Jugular chain -> anterior to the SCM. Cervical and supraclavicular lymph nodes Posterior triangle nodes -> posterior to the SCM. Occipital nodes Post-auricular nodes -> behind the ears. Pre-auricular -> in front of the ears. From the front of the patient -> ask them to shrug their shoulders -> feel in the supraclavicular fossa and the based of the sternomastoid muscle -> super clavicular nodes. Small cervical lymph nodes can be palpable in in healthy young people. Patient sitting up. Gently but firmly tap over the spine with your fist for bony tenderness -> enlarged marrow due to infiltration by: Multiple myeloma Lymphoma Bone tenderness Carcinoma Malignant bone disease. Gently press over the sternum with the heel of the hand. Gently press over both clavicles with the heel of the hand. Test both shoulders by pushing them towards each other with your hands. Lay the patient flat again Palpate the spleen Look for splenomegaly Spleen percussion -> Traube space and method. Patient in supine position. Slightly abduct the patient’s left arm. Ask the patient to normally breath. Percuss across the space from medial to lateral margins at a couple of levels. NOTE SHOULD REMAIN RESONANT UNLESS THERE IS ENLARGEMENT. Spleen percussion -> castell space and method. Patient in supine position. Percuss over castell’s spot. Abdomen Percuss over the lowest left intercoastal space in the anterior axillary line with patient in full inspiration and expiration. The note will become dull during inspiration if the spleen is enlarged. Sensitivity and specificity -> 82% and 83% respectively. Examine for hepatomegaly Palate for inguinal lymph nodes Palpate for para-aortic nodes. Lymphoma Lymphatic leukemia Look for testicular masses. Rectal examination Evidence of rectal bleeding. Evidence of carcinoma. Two groups: Along the inguinal ligament Inguinal lymph nodes Along the femoral vessels. Small, firm mobile nodes are commonly found in thin healthy people. Inspect for: Petechiae Brusing Pigmentation Starch marks. Palpable purpura over the buttocks and the legs -> present in Henoch-Schoenlein purpura. Drug reactions may cause petechia or purpura on the legs or anywhere else. Look for leg ulcers above the medial and lateral malleolus. Haemolytic anaemia due to infarction due to abnormal blood viscosity. Thalassemia Macroglobulinaemia Thrombotic thrombocytopenia purpura Polycythaemia Legs Felty’s syndrome Chronic use of hydroxyurea for myeloproliferative disorders -> malar ulcers Popliteal lymph nodes Examine for evidence of neurological abnormalities Vit B12 deficiency (may also cause optic atrophy and mental changes). Lack methadone Leg or wrist drop Led poisoning Signs of venous diseases: Signs of DVT. Examine the weight bearing joints for: Signs of deformities from hemarthrosis in patients with haemophilia. Chronic arthritis from hemarthrosis in patients with haemophilia. Examine the fundi. Increase in blood viscosity: Occurs in macroglobulinaemia, myeloproliferative diseases or chronic granulocytes. Fundi Haemorrhage Haemostatic disorder Retinal lesions Multiple y