Examining the patient

Published on 03/04/2015 by admin

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Last modified 03/04/2015

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Examining the patient

Abnormalities of the blood may arise as a result of a primary disorder of the bone marrow (e.g. leukaemia) or from a wide range of systemic disorders. A thorough clinical examination is vital both to confirm a likely diagnosis and to exclude coexistent problems. There is not space here to detail all the elements of clinical examination; we have concentrated on aspects of the examination most relevant to patients with a primary blood disorder.

Look at the patient!

It is easy to examine a patient carefully without properly observing them. A deliberate inspection of the patient’s face while taking the history may reveal vital clues even before the formal examination is commenced. Common examples include the pallor of iron deficiency anaemia, the lemon tint of megaloblastic anaemia, the jaundice of a haemolytic anaemia, and the plethora of polycythaemia. Before laying a hand on the patient, a careful inspection of the mouth and skin may also point to particular blood abnormalities or disorders (Table 8.1). The patient’s ethnic origin can be of relevance. Sickle cell anaemia is an unlikely diagnosis in a patient with white skin while pernicious anaemia is equally unlikely in a patient with black skin. Children with chronic blood disorders such as haemoglobinopathies are frequently thinner and shorter than their healthy peers.

Table 8.1

Observation of the patient with a blood disorder. Some common signs and their possible clinical relevance

Clinical sign	Possible haematological abnormality
Face
Pallor	Any anaemia
Lemon tint	Megaloblastic anaemia
Jaundice	Haemolytic anaemia
Plethora	Polycythaemia
Mouth
Ulcers	Neutropenia
Glossitis	Megaloblastic anaemia
	Iron deficiency anaemia
Angular stomatitis	Iron deficiency anaemia
Candida (‘thrush’)	Immunosuppression
Skin
Pallor	Any anaemia
Jaundice	Haemolytic anaemia
Excessive bruising	Coagulation disorder, thrombocytopenia
Purpuric/petechial rash	Thrombocytopenia
Leg ulcers	Sickle cell anaemia

General examination

Careful observation should be followed by a methodical examination of the major systems. The possible abnormalities in each system which may be seen in blood diseases are too numerous to detail here. They are referred to in the relevant sections describing each disease. Although examination should be ordered, in a busy clinical practice it is often necessary to prioritise. Rectal examination is not routine in all patients with blood disorders but is definitely indicated in unexplained iron deficiency to exclude an otherwise asymptomatic rectal carcinoma; it is contraindicated in patients with suspected leukaemia and neutropenia. Similarly, an exhaustive examination of the major joints is not universally performed but is crucial in a patient with haemophilia.

Examination of the lymph nodes

Lymph nodes may be enlarged in primary blood disorders and systemic diseases. Enlargement is referred to as ‘lymphadenopathy’ or just ‘adenopathy’. The differential diagnosis differs in generalised and localised forms of lymphadenopathy (Table 8.2). In practice, palpable lymphadenopathy is usually limited to the cervical, axillary and inguinal areas.

Table 8.2

Common causes of lymphadenopathy

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