History taking

Published on 03/04/2015 by admin

Filed under Hematology, Oncology and Palliative Medicine

Last modified 03/04/2015

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History taking

Abnormalities of the blood are associated with a wide range of symptoms and these are discussed in detail under diagnostic headings in subsequent sections. The intention of this section is to give an overview of history taking in patients with blood disorders. Despite the advent of sophisticated laboratory equipment to test blood, a thorough history remains fundamental to accurate diagnosis. In practice the history may precede and then follow the knowledge of a laboratory test abnormality. Whatever the order of events, only by considering symptoms, physical signs and laboratory results in conjunction can the correct conclusion be reached and the patient be managed in the appropriate psychosocial setting (Fig 7.1).

Fig 7.1 The history, clinical examination and laboratory investigations are all essential in the diagnosis of a disorder of the blood.

History of the presenting complaint

Patients may be asymptomatic and have an unpredictable abnormality detected on a routine blood count. Other patients present to the doctor with complaints dependent on the nature of the change in the blood. Some will have several blood abnormalities and present with a large number of symptoms. Despite this complexity it is possible to highlight some common groups of symptoms (Table 7.1).

Table 7.1

Common haematological abnormalities and associated symptoms

Nature of abnormality¹	Commonly associated symptoms
Anaemia	Fatigue, weakness, dyspnoea, palpitations, headache, dizziness, tinnitus
Leucopenia (particularly neutropenia)	Unusually severe or recurrent infections
Thrombocytopenia	Easy bruising, excessive bleeding after trauma, spontaneous bleeding from mucous membranes
Defective coagulation (e.g. key factor deficiency)	Excessive bleeding after trauma, spontaneous bleeds into joints and muscles
Infiltration by malignancy (e.g. leukaemia, lymphoma)	‘Lumps’ caused by lymphadenopathy, pain, neurological symptoms

¹ The haematological abnormalities have many possible causes but will always tend to lead to the symptoms shown.

Symptoms attributable to anaemia (low haemoglobin concentration)

Patients with anaemia have a reduced supply of oxygen to the tissues. Symptoms include fatigue, weakness, dyspnoea, palpitations, headaches, tinnitus and chest pain (due to exacerbation of angina). The symptoms are affected not only by the severity of the anaemia but by its speed of onset. Anaemia which develops rapidly is usually less well tolerated and patients are more debilitated.

Symptoms attributable to a low white cell count (leucopenia)

It is usually a reduction in neutrophils (neutropenia) which causes clinical problems. Patients are susceptible to infections, the risk rising sharply at neutrophil counts below 0.5 × 10⁹/L. Serious blood diseases such as acute leukaemia can present as life-threatening infections or as apparently trivial infections (e.g. a sore throat) which are unusually refractory to normal treatment. Perineal sepsis can be a particular problem.

Symptoms attributable to a low platelet count (thrombocytopenia)

Thrombocytopenia leads to a haemorrhagic tendency and common presentations include epistaxes (nose bleeds), bleeding from gums, menorrhagia (heavy periods) and excessive bleeding after trauma or surgery. Patients may also complain of easy bruising or a petechial rash. Spontaneous bleeding is usually restricted to platelet counts below 20 × 10⁹/L. In disorders of platelet function similar symptoms may occur even when the count is normal.

Symptoms attributable to abnormal coagulation

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