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Chapter 1: Approach to the Patient

FINDINGS THAT MAY LEAD TO A HEMATOLOGY CONSULTATION

Table 1–1 lists abnormalities that often require an evaluation by a hematologist.

TABLE 1–1FINDINGS THAT MAY LEAD TO A HEMATOLOGY CONSULTATION
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TABLE 1–1 FINDINGS THAT MAY LEAD TO A HEMATOLOGY CONSULTATION

Decreased hemoglobin concentration (anemia)

Increased hemoglobin concentration (polycythemia)

Elevated serum ferritin level

Leukopenia or neutropenia

Immature granulocytes or nucleated red cells in the blood

Pancytopenia

Granulocytosis: neutrophilia, eosinophilia, basophilia, or mastocytosis

Monocytosis

Lymphocytosis

Lymphadenopathy

Splenomegaly

Hypergammaglobulinemia: monoclonal or polyclonal

Purpura

Thrombocytopenia

Thrombocytosis

Exaggerated bleeding: spontaneous or trauma related

Prolonged partial thromboplastin or prothrombin coagulation times

Venous thromboembolism

Thrombophilia

Obstetrical adverse events (eg, recurrent fetal loss, stillbirth, and HELLP* syndrome)

*Hemolytic anemia, elevated liver enzymes, and low platelet count.

Source: Williams Hematology, 9th ed, Chap. 1, Table 1–1.

The care of a patient with a hematologic disorder begins with eliciting a medical history and performing a thorough physical examination. Certain parts of the history and physical examination that are of particular interest to the hematologist are presented here.

HISTORY OF THE PRESENT ILLNESS

  • Estimation of the “performance status” helps establish the degree of disability and permits assessment of the effects of therapy (Tables 1–2 and 1–3).

  • Drugs and chemicals may induce or aggravate hematologic diseases; drug use or chemical exposure, intentional or inadvertent, should be evaluated. One should inquire about professionally prescribed and self-prescribed drugs, such as herbal remedies. Occupational exposures should be defined.

  • Fever may result from hematologic disease or, more often, from an associated infection. Night sweats suggest the presence of fever. They are especially prevalent in the lymphomas.

  • Weight loss may occur in some hematologic diseases.

  • Fatigue, malaise, lassitude, and weakness are common but nonspecific symptoms and may be the result of anemia, fever, or muscle wasting associated with hematologic malignancy or neurologic complications of hematologic disease.

  • Symptoms or signs related to specific organ systems or regions of the body may arise because of involvement in the basic disease process, such as spinal cord compression from a plasmacytoma, ureteral or intestinal obstruction from abdominal lymphoma, or stupor from exaggerated hyperleukocytosis in chronic myelogenous leukemia.

TABLE 1–2CRITERIA OF PERFORMANCE STATUS (KARNOFSKY SCALE)
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TABLE 1–2 CRITERIA OF PERFORMANCE STATUS (KARNOFSKY SCALE)
Able to carry on normal activity; no special care is needed.
100% Normal; no complaints, no evidence of disease
90% Able to carry on normal activity; minor signs or symptoms of disease
80% Normal activity with effort; some signs or symptoms of disease
Unable to work; able to live at home, care for most personal needs; a varying amount of assistance is needed.
70% Cares for self; unable to carry on normal activity or to do active work
60% Requires occasional assistance but is able to ...

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