History taking

Published on 03/04/2015 by admin

Filed under Hematology, Oncology and Palliative Medicine

Last modified 22/04/2025

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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.

Systemic enquiry

A thorough systemic enquiry is essential as blood abnormalities are more often caused by a general systemic disorder than by a specific blood disease. It can be difficult to establish whether the primary problem is in the bone marrow or if the blood is ‘reacting’ to pathology elsewhere. One example is a high platelet count (thrombocytosis). This may be caused by the bone marrow disorder essential thrombocythaemia but equally can be secondary to infection, inflammation or malignancy (‘reactive thrombocytosis’). Only by excluding a non-haematological aetiology can the diagnosis of essential thrombocythaemia be confidently made. On occasion the haematological diagnosis prompts a return to a particular part of the systemic enquiry. Thus the finding of unexplained iron deficiency necessitates an exhaustive enquiry for symptoms of gastrointestinal disease associated with chronic blood loss.

Past medical history

It is important to elicit a history of diseases which may have caused a haematological abnormality or which may affect the management of a primary blood disorder such as leukaemia. Where there is a known abnormality in the blood count it is helpful to establish whether previous counts have been performed. Where past results are available they will clarify whether the problem is of recent onset or longstanding. For patients presenting with easy bruising or bleeding, previous surgical exposure is of particular interest. The lack of excessive bleeding after surgery suggests that the bleeding tendency is either of limited significance or of more recent onset.

Drugs can cause haematological problems – some commoner examples are listed in Table 7.2. A careful drug history (wherever possible verified by checking tablets) may suggest a likely offending agent. If the problem is of sufficient severity to cause concern the drug should ideally be discontinued and the blood count monitored to check resolution. It is as relevant to obtain a history of allergy in haematology as in other areas of medicine. Indeed, patients with haematological malignancies are often given an unusually large number of chemotherapeutic and antimicrobial agents and possible reactions have to be vigilantly documented to avoid repeat exposure.

Table 7.2

Possible haematological side-effects of drugs

Haematological abnormality	Drugs¹
Marrow aplasia	Chloramphenicol (idiosyncratic)
	Cytotoxics (dose-related)
Haemolytic anaemia	Cephalosporins
	Penicillins
Leucopenia/agranulocytosis	Phenothiazines
	Sulphonamides
Thrombocytopenia	Quinine
	Thiazide diuretics

¹ Many drugs have been implicated in all these abnormalities – the examples shown are some of the more common offenders.

Family history

As can be seen from Table 7.3, a number of blood diseases are inherited. A knowledge of the mode of inheritance is useful in diagnosis and essential in counselling the patient and family. A simple question as to the presence of ‘anaemia’ or a ‘bleeding problem’ in other family members can prevent unnecessary investigation and delay in diagnosis.

Table 7.3

Some inherited blood disorders

Red cell disorders
Disorders of the membrane	Hereditary spherocytosis and elliptocytosis
Disorders of haemoglobin	Thalassaemias and sickle syndromes
Disorders of metabolism	Glucose-6-phosphate dehydrogenase and pyruvate kinase deficiencies
Coagulation disorders
Factor deficiency	Haemophilia A and B
Combined factor and platelet abnormality	von Willebrand disease
Platelet abnormality	Bernard–Soulier syndrome (rare)
White cell disorders	Rare functional disorders (e.g. chronic granulomatous disease)