Taking history and physical examination in hematopoietic system akk
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The document outlines the process of taking a medical history and conducting a physical examination focused on the hematopoietic system. It emphasizes systematic approaches to assess symptoms, previous medical records, and general health, along with various performance status scales. Additionally, it details specific symptoms and physical examination techniques relevant to hematologic conditions, providing comprehensive guidelines for healthcare professionals.
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The History- General Symptoms & Signs
• Performance status
• Weight loss
– is a frequent accompaniment of many serious diseases,
including primary hematologic malignancies, but it is
not a prominent accompaniment of most hematologic
diseases.
• Fever
– Pyrogenic cytokines (e.g., interleukin [IL]-1, IL-6, and IL-
8) in aggressive lymphoma, acute leukemia, primary
myelofibrosis, severe hemolytic anemia
– Neutropenia
• Night sweats](https://image.slidesharecdn.com/takinghistoryandphysicalexaminationinhematopoieticsystemakk-191126112211/85/Taking-history-and-physical-examination-in-hematopoietic-system-akk-6-320.jpg)
Taking history and physical examination in hematopoietic system akk
- 1. 1 History Taking and Physical Examination of the Hematopoietic System Asst. Prof. Aşkın K. KAPLAN, M.D. Maltepe University Maltepe Faculty of Medicine
- 2. 2 Assessment of a Patient in Hematology • Medical history taking • Physical examination
- 4. 4 Medical History • Determine the nature of the illness • Identify patient’s symptoms systematically – Obtain as much relevant information as possible about their origin and evolution and about the general health of the patient by appropriate questions A good doctor had to be able not simply to ask the right questions, but also to look for the right answers
- 5. 5 Medical History • Medical history taking – Assessment of symptoms – Reviewing previous records • Understanding the onset or progression of illness – Personal medical history for other disorders that can cause blood count abnormalities • Hematologic manifestations secondary to other diseases occur more frequently than primary hematologic diseases – Person’s ethnicity or race – Exposures; drugs, chemicals, toxins, radiation, alcohol – Family history
- 6. 6 The History- General Symptoms & Signs • Performance status • Weight loss – is a frequent accompaniment of many serious diseases, including primary hematologic malignancies, but it is not a prominent accompaniment of most hematologic diseases. • Fever – Pyrogenic cytokines (e.g., interleukin [IL]-1, IL-6, and IL- 8) in aggressive lymphoma, acute leukemia, primary myelofibrosis, severe hemolytic anemia – Neutropenia • Night sweats
- 7. 7 Performance Status- Karnofsky Scale • Establish semiquantitatively the extent of a patient’s disability 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 care for most personal needs 50% Requires considerable assistance and frequent medical care Unable to care for self; requires equivalent of institutional or hospital care; disease may be progressing rapidly. 40% Disabled; requires special care and assistance 30% Severely disabled; hospitalization is indicated though death not imminent 20% Very sick; hospitalization necessary; active supportive treatment necessary 10% Moribund; fatal processes progressing rapidly 0% Dead
- 8. 8 Eastern Cooperative Oncology Group (ECOG) Performance Status Grade Activity 0 Fully active, able to carry on all predisease performance without restriction 1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature 2 Ambulatory and capable of all self-care but unable to carry out any work activities; up and about more than 50% of waking hours 3 Capable of only limited self-care, confined to bed or chair more than 50% of waking hours 4 Completely disabled; cannot carry on any self-care; totally confined to bed or chair 5 Dead
- 9. 9 • Fatigue, malaise, and lassitude – Anemia – Malignancies The History- General Symptoms & Signs
- 10. 10 • Weakness; general loss of strength or reduced capacity for exercise – Anemia – Wasting of malignant processes – Neurologic complications of hematologic disease; • vitamin B12 deficiency • monoclonal immunoglobulinemias • Central or peripheral nervous system invasion or compression as a result of vertebral collapse, a paraneoplastic syndrome (e.g., encephalitis), or brain or meningeal involvement. • Myopathy secondary to malignancy; usually manifest as weakness of proximal muscle groups. • Foot drop or wrist drop; lead poisoning, amyloidosis, systemic autoimmune diseases, or vincristine therapy • Paralysis may occur in acute intermittent porphyria. The History- General Symptoms & Signs
- 11. 11 The History- Spesific Symptoms or Signs • Headache • Paresthesias • Confusion • Impairment of consciousness Nervous System
- 12. 12 The History- Spesific Symptoms or Signs • Epistaxis • Anosmia; – pernicious anemia, malignancy, opportunistic infections • Pain or tingling in the tongue – Pernicious anemia, iron deficiency, vitamin deficiency • Macroglossia • Bleeding gums – Bleeding disorders, acute leukemia • Ulcerations – Neutropenia • Dryness – Hypercalcemia • Dysphagia – Iron deficiency anemia • Painless swelling in the neck – Lymphadenopathy – Superior vena cava obstruction Head & Neck • Conjunctical pallor, plethora • Blindness;retinal hemorrhages • Blurred vision; hyperviscosity • Complete or partial visual loss; retinal vein or artery thrombosis • Diplopia • Disturbances of ocular movement – Paralysis of the 3rd, 4th, or 6th cranial nerves • Vertigo, tinnitus, roaring in the ears – Anemia, polycytemia
- 13. 13 Chest & Heart • Dyspnea • Palpitations • Congestive heart failure • Angina pectoris • Cough – Enlarged mediastinal nodes • Chest pain – Involvement of the ribs or sternum with lymphoma or multiple myeloma – Nerve root invasion or compression – Herpes zoster – Pulmonary infarct • Hemoptysis • Tenderness of the sternum – Leukemias – Primary myelofibrosis – Lymphoma, myeloma Gastrointestinal System • Dysphagia • Anorexia • Indigestion • Abdominal fullness • Premature satiety – Splenomegaly • Abdominal pain – Obstruction, retroperitoneal bleeding, lead poisoning, ileus, acute hemolysis, sickle cell disease, acute intermittent porphyria • Diarrhea – Malabsorption • Gastrointestinal bleeding • Constipation – Hypercalcemia – Vinca alkaloids The History- Spesific Symptoms or Signs
- 14. 14 Genitourinary & Reproductive System • Impotence or bladder dysfunction – Spinal cord or peripheral nerve damage • Priapism – Leukemia, essential thrombocytemia, or sickle cell anemia • Hematuria • Red urine; hemoglobinuria – Intravascular hemolysis, myoglobinuria, or porphyrinuria • Amenorrhea • Menorrhagia Back & Extremities • Back pain • Arthritis • Arthralgia • Hemarthroses • Shoulder pain • Bone pain • Edema The History- Spesific Symptoms or Signs
- 15. 15 Skin • Dryness – Iron deficiency • Nail abnormalities – Brittles • Jaundice • “Lemon yellow” skin – Pernicious anemia • Pallor • Erythromelalgia – Polycythemia vera, E. throbocytemia • Erythroderma, infiltrative lesions • Cyanosis – Methemoglobinemia – Abnormal hemoglobins with high oxygen affinity • Itching – Hodgkin lymphoma, mycosis fungoides • Petechiae, purpura, ecchymoses • Easy bruising • Leg ulcers – Sickle cell anemia The History- Spesific Symptoms or Signs
- 16. 16 The History- Drugs & Chemicals • Complete history of drug use • Detailed information on alcohol consumption from every patient – Amount, duration.. • Patients should be asked about the use of recreational drugs. – The use of “alternative medicines” and herbal – Nonjudgmental questioning may be successful in identifying agents in this category
- 17. 17 The History • Vaccination – Immune thrombocytopenia • Nutrition – Dietary deficiency in anemia • Sexual history – HIV infection • Family History – Hemoglobinopathies – Bleeding manifestations – Venous thromboembolism
- 18. 18 Preventive Hematology • Identification of individual genetic risk factors • Avoidance of situations that may make a latent disorder manifest. • Prophylactic therapy – Anticoagulant prophylaxis for venous stasis • Elimination of sources of environmental factors • Prenatal diagnosis
- 19. 19 Physical Examination • Performance status • Skin and mucous membranes • Nervous system • Head & neck examination • Lymph node examination • Abdominal examination for enlargement of the spleen and liver • Musculoskeletal system • Rectal examination if necessary for the assessment of stool for blood
- 20. 20 Physical Examination- Skin • The color of the skin – Pallor; anemia – Redness; polycythemia • The mucous membranes and nail beds are usually more reliable guides to anemia or polycythemia than the skin • The palmar creases are useful guides to the hemoglobin level • Liver disease may induce flushing of the thenar and hypothenar eminences of the palm, even in patients with anemia
- 21. 21
- 22. 22 normal soluk
- 23. 23
- 24. 24 Physical Examination- Skin • Cyanosis – Is a function of the total amount of reduced hemoglobin, methemoglobin, or sulfhemoglobin present – The minimum amounts of these pigments that cause detectable cyanosis are approximately 5 g/dL blood of reduced hemoglobin, 1.5 to 2.0 g/dL of methemoglobin, and 0.5 g/dL of sulfhemoglobin
- 25. 25 Physical Examination- Skin • Jaundice – Staining of the skin by bile pigment, and bilirubin glucuronide – Jaundice of the skin may not be visible if the bilirubin level is below 2 to 3 mg/dL
- 26. 26 Physical Examination- Skin • Petechiae – Small (1 to 2 mm), round, red or brown lesions – Present primarily in areas with high venous pressure, such as the lower extremities – These lesions do not blanch on pressure – Palpable petechiae; vasculitis • Ecchymoses – May be of various sizes and shapes and may be red, purple, blue, or yellowish green, depending on the intensity of the skin hemorrhage and its age
- 27. 27 Bleeding Diathesis- Thrombocytopenia • May be asymptomatic • Mucocutaneous bleeding is characteristic
- 28. 28 Physical Examination- Skin • Excoriation – Itching; Hodgkin lymphoma • Leg ulcers – Sickle cell anemia – Hereditary anemia • Nails – In chronic severe iron- deficiency anemia nails may be ridged longitudinaly – Koilonychia; flattened or concave nails
- 29. 29 Physical Examination- Eyes • Jaundice, pallor, or plethora • Retinal hemorrhages and exudates • Dilatation of the veins – Polycythemia – Macroglobulinemia
- 30. 30 Physical Examination- Mouth • Pallor of the mucosa; anemia • Ulceration; neutropenia • Swelling of the gums; acute leukemia • Bleeding from the mucosa • Dark line of gums; lead poisining • Smooth and red tongue; pernicious or iron deficiency anemia • Macroglossia; primary amyloidosis
- 31. 31 Anemia
- 32. 32 Lymphoid Organs • Primary lymphoid organs – Bone marrow – Thymus • Secondary lymphoid organs – Lymph node – Spleen – Peyer patches – Waldeyer ring (tonsils, adenoids)
- 33. 33 Lymph Node Regions in Lymphoma
- 34. 34 Physical Examination- Lymph Nodes • Palpable lymph node regions – Suboccipital, auricular, cervical, supraclavicular, axillary, epitrochlear, inguinal, or iliofemoral, popliteal • In inguinal area 0.5 to 2.0 cm lymph node can be found in normal individuals • 0.5 to 1.0 cm nodes may be palpated in the cervical region • Palpation should be gentle and is best performed with a circular motion of the fingertips, using slowly increasing pressure • Tender lymph nodes usually indicate an inflammatory etiology
- 35. 35 Physical Examination- Chest • Increased rib or sternal tenderness • Increased bone pain – Leukemia, multiple myeloma, metastatic tumors
- 36. 36 Physical Examination • Spleen – Masses in the stomach, colon, kidney, or pancreas may mimic splenomegaly on physical examination • Liver – It is necessary to determine both the upper and lower borders of the liver by percussion in order to properly assess liver size – The normal liver may be palpable as much as 4 to 5 cm below the right costal margin
- 37. 37 Physical Examination- Nervous System • Vitamin B12 deficiency • Leukemic meningitis • Brain or spinal cord compression • Neurologic abnormalities – Leukemia, lymphoma, myeloma related tumor infiltration, bleeding, infection, or paraneoplastic syndrome • Neuropathies – Monoclonal gammopathy • Polyneuropathy – POEMS; polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes
- 38. 38 Physical Examination- Joints • Hemorrhage in patients with hemophilia
- 39. 39 Neutropenic Fever- Physical Examination Site Findings Lung Hypoxia, tachypnea, shortness of breath Abdomen Peritoneal signs and/or abdominal tenderness Even when an abdominal process is present, abdominal signs may be subtle or absent in neutropenic patients. Catheter sites Slight erythema or tenderness Fluctuance or exudates are unlikely since the lack of inflammatory cells inhibits the development of inflammatory reactions. Skin/mucous membranes Erythema, rash, cellulitis, ulcers, furuncles, vesicles, paronychia, mucositis, dental or peritonsillar cellulitis, perianal fissures, and pilonidal disease. Perianal region Erythema, pain on palpation, and tender hemorrhoids Digital rectal examination (and rectal temperatures) should be avoided so that one does not introduce infection by traumatizing the fragile mucosa.
- 40. 40 Reference • Williams Hematology, 9th ed 2016, by McGraw-Hill Education. Marshall A. Lichtman; Linda J. Burns – Clinical evaluation of the patient
- 41. 41 Thank You Asst. Prof. Aşkın K. Kaplan M.D. [email protected]
- 42. 42 History of Present Illness - HPI • Fatigue anaemia • Weakness anaemia • Palpitations anaemia • Swollen ankles lymphoedema • Postural dizzyness anaemia • Bleeding thrombocytopenia or clot disorder • Bruising thrombocytopenia or clot disorder • Fever cancer • Night sweats cancer • Weight loss cancer • Jaundice hemolysis or liver dysfunction • Lymph n enlargement cancer • Lumps of any sort? cancer • Bone pain cancer mets • Tingling and loss of sensation B12 deficit anaemia • Skin rash lupus / bacyteraemia / cancer / autoimmune hemolytic anaemia