Physical examination

This forms part of the clinical assessment of the haematology patient. Pay specific attention to:

General examination—e.g. evidence of weight loss, pyrexia, pallor (not a reliable clinical measure of anaemia), jaundice, cyanosis or abnormal pigmentation or skin rashes.

The mouth—ulceration, purpura, gum bleeding or infiltration, and the state of the patient's teeth. Hands and nails may show features associated with haematological abnormalities e.g. koilonychia in chronic iron deficiency (rarely seen today).

Record—weight, height, T°, pulse and blood pressure; height and weight give important baseline data against which sequential measurements can subsequently be compared. In myelofibrosis, for example, evidence of significant weight loss in the absence of symptoms may be an indication of clinical progression.

Examination—of chest and abdomen should focus on detecting the presence of lymphadenopathy, hepatic and/or splenic enlargement. Node sizes and the extent of organ enlargement should be carefully recorded.

Lymph node enlargement—often recorded in centimetres e.g. 3cm X 3cm X 4cm; sometimes more helpful to compare the degree of enlargement with familiar objects e.g. pea. Record extent of liver or spleen enlargement as maximum distance palpable from the lower costal margin.

Erythematous margins of infected skin lesions—mark these to monitor treatment effects.

Bones and joints—recording of joint swelling and ranges of movement are standard aspects of haemophilia care. In myeloma, areas of bony tenderness and deformity are commonly present.

Optic fundi—examination is a key clinical assessment in the haematology patient. May yield the only objective evidence of hyperviscosity in paraproteinaemias (^Emergencies p510) or hyperleucocytosis (^Emergencies p510) such as in e.g. CML. Regular examination for haemorrhages should form part of routine observations in the severely myelosuppressed patient; rarely changes of opportunistic infection such as candidiasis can be seen in the optic fundi.

Neurological examination—fluctuations of conscious level and confusion are clinical presentations of hyperviscosity. Isolated nerve palsies in a patient with acute leukaemia are highly suspicious of neurological involvement or disease relapse. Peripheral neuropathy and long tract signs are well recognised complications of B12 deficiency.

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