��Prof. Andrzej Hellmann Prof. Andrzej Hellmann History taking and physical examination History taking and physical examination in haematology in haematology Department of Haematology and Transplantology Department of Haematology and Transplantology . . �% History taking  anamnesis �% History taking  anamnesis �% Physical examination �% Physical examination �% Auxillary investigations �% Auxillary investigations - Laboratory tests - complete Blood Count - CBC - Laboratory tests - complete Blood Count - CBC - coagulation tests - coagulation tests - bone marrow examination - bone marrow examination - immunophenotyping - immunophenotyping - cytogenetics - cytogenetics - molecular investigations (PCR) - molecular investigations (PCR) - histopatology - histopatology - Noninvasive imaging - radiology - Noninvasive imaging - radiology technique: - ultrasonography technique: - ultrasonography - computed tomography (CT) - computed tomography (CT) - positron emission tomopraphy (PET) - positron emission tomopraphy (PET) - scyntypraphy - scyntypraphy Consulting the results Consulting the results " Anaemia (Hb <� 11g/dl.) " Anaemia (Hb <� 11g/dl.) �! 90% �! 10% �! 90% �! 10% non  haematological haematological non  haematological haematological causes diseases causes diseases Leucocytosis Leucocytosis probability of causes probability of causes > 15G/l ~ 53% infections > 15G/l ~ 53% infections ~ 24% stress ~ 24% stress ~ 11% drugs ~ 11% drugs ~ 6% necrosis ~ 6% necrosis ~ 6% leucaemias ~ 6% leucaemias >30G/l ~ 40% infekctions >30G/l ~ 40% infekctions 10% tumors 10% tumors 8% drugs 8% drugs 42% leucaemias 42% leucaemias > 100G/l ~ 95% leucarmias > 100G/l ~ 95% leucarmias 3% tumors 3% tumors 2% tuberculosis 2% tuberculosis Thrombocytosis Thrombocytosis PLT > 450 G/l 50% infections PLT > 450 G/l 50% infections 25% sideropenia 25% sideropenia 25% tumors 25% tumors 10% thrombocythaemia 10% thrombocythaemia PLT > 600 G/l 10% infections PLT > 600 G/l 10% infections 10% sideropenia 10% sideropenia 20% tumors 20% tumors 60% thrombocythaemia 60% thrombocythaemia PLT > 1000 G/l 95% thrombocythaemia PLT > 1000 G/l 95% thrombocythaemia 3% splenectomy 3% splenectomy 2% other reasons 2% other reasons History taking History taking " Family history " Family history " Social history " Social history " Past medical history " Past medical history " Present complains " Present complains Family history Family history �% haematology is rich in heritable diseases, hemophilia, non-immune �% haematology is rich in heritable diseases, hemophilia, non-immune haemolytic anaemias haemolytic anaemias �% Patern of inheritance �% Patern of inheritance Family history (continue) Family history (continue) in acute leucaemias and other haematologial disorders we have to look in acute leucaemias and other haematologial disorders we have to look for potential donors for bone marrow transplantation. for potential donors for bone marrow transplantation. Siblings not stepsiblings Siblings not stepsiblings formula 1  (0,75)n - number of brothers or sisters formula 1  (0,75)n - number of brothers or sisters 1 brother or sister - 25,0% 1 brother or sister - 25,0% 2 siblings - 43,7% 2 siblings - 43,7% 3  - 67,2% 3  - 67,2% 4  - 68,4% 4  - 68,4% 5  - 76,3% 5  - 76,3% 6  - 82,2% 6  - 82,2% 7  - 86,6% 7  - 86,6% Social history Social history Profession: environmental exposures Profession: environmental exposures Living conditions: disstance to the hospital Living conditions: disstance to the hospital Nutrition habits : vegetarian,veganian habits Nutrition habits : vegetarian,veganian habits alcohol consumption alcohol consumption tabacco tabacco Past medical history Past medical history �% surgical procedures �% surgical procedures - cholecystectomy - cholecystectomy - splenectomy - splenectomy - gastrectomy - gastrectomy - jejunectomy - jejunectomy �% radiotherapy, cytostatics �% radiotherapy, cytostatics �% farmacotherapy: anticonvulsant drugs �% farmacotherapy: anticonvulsant drugs nonsteroidal antiinflammatory agents nonsteroidal antiinflammatory agents gold gold Transfusion history Transfusion history �% blood donation (1 ~ 200  250 mg Fe) �% blood donation (1 ~ 200  250 mg Fe) �% history of blood taking �% history of blood taking - haemosyderosis  after (50j ME  10g Fe) - haemosyderosis  after (50j ME  10g Fe) �% Jehovah`s witnesses �% Jehovah`s witnesses Present complains Present complains �% fatigue, weakness  may be related to anaemia �% fatigue, weakness  may be related to anaemia �% headache  may be due to anaemia or polycythemia or �% headache  may be due to anaemia or polycythemia or may by caused infiltration of CNS may by caused infiltration of CNS �% weight loss  may occur in leucaemias and lymphomas, �% weight loss  may occur in leucaemias and lymphomas, but more prominent is rather due to but more prominent is rather due to nonhaematological malignancies nonhaematological malignancies Present complains (continue). Present complains (continue). �% fever: usually is due to secondary infections, but quite �% fever: usually is due to secondary infections, but quite offen may be caused by the disease itself (NHL, HL, offen may be caused by the disease itself (NHL, HL, ALL) ALL) �% night sweats: may occur in patients with lymphoma �% night sweats: may occur in patients with lymphoma �% chills: may accompany severe haemolytic anaemia �% chills: may accompany severe haemolytic anaemia Present complains (continue) Present complains (continue) �% itching  may occur in HL, NHL (Sezary syndrome) �% itching  may occur in HL, NHL (Sezary syndrome) PV (after bathing) PV (after bathing) �% erythromelalgia  burning pain increased skin temperature and �% erythromelalgia  burning pain increased skin temperature and redness of the feet less often hands  often in redness of the feet less often hands  often in thrombocythaemia thrombocythaemia �% lef upper �% lef upper quadrant of abdomen pain, quadrant of abdomen pain, fullness is due splenomegaly fullness is due splenomegaly �% left shoulder aching �% left shoulder aching Physical examination Physical examination �% examination of the skin and mucous membrances (oral cavity) �% examination of the skin and mucous membrances (oral cavity) �% examination of the lymph-nodes �% examination of the lymph-nodes �% examination of the spleen �% examination of the spleen �% Examination of the skin and mucous membrences �% Examination of the skin and mucous membrences - pallor - pallor - jaundice - jaundice - flusing (plethora) - flusing (plethora) - petechiae - petechiae - ecchymoses - ecchymoses ecchymoses ecchymoses petechiae petechiae Infiltration of the gums Infiltration of the gums Skin in GvHD Skin in GvHD Examination of lymph nodes Examination of lymph nodes Lymphadenopathy " e" 1 cm. Lymphadenopathy " e" 1 cm. Reactive - soft and tender, mobile usually less than 2 cm " Reactive - soft and tender, mobile usually less than 2 cm " Malignant  large, rubbery, painless, matted and fixed Malignant  large, rubbery, painless, matted and fixed Lymphadenopaty may be  isolated (single) Lymphadenopaty may be  isolated (single) - regional - regional - genaralised - genaralised supraclavicular preauricular supraclavicular submental cervical supraclavicula supraclavicular r axillary epitrochlear supracla paraaortic vicular submental inguinal popliteall Expression of the lymph  node size Expression of the lymph  node size diametr volume diametr volume 3.,0 cm 9,4 cm3 3.,0 cm 9,4 cm3 3,5 cm 22,0 cm3 3,5 cm 22,0 cm3 4,0 cm 33,5 cm3 4,0 cm 33,5 cm3 wg Wiseman et al., Blood 2001 wg Wiseman et al., Blood 2001 Differential diagnosis of lymphadenopathy Differential diagnosis of lymphadenopathy I Infections: I Infections: a. Bacterial: tuberculosis, syphilis, staphylococcal, streptococcal a. Bacterial: tuberculosis, syphilis, staphylococcal, streptococcal b. Viral: CMV, HIV, EB b. Viral: CMV, HIV, EB c. Parasitic: toxoplasmosis c. Parasitic: toxoplasmosis d. Rickettsial: d. Rickettsial: II Inflamatory: sarcoidosis, rheumatoid arthritis,systemic lupus II Inflamatory: sarcoidosis, rheumatoid arthritis,systemic lupus erythematosus erythematosus III Malignant: HL, NHL, CLL, ALL III Malignant: HL, NHL, CLL, ALL Conditions Metastatic disease Conditions Metastatic disease �% Examination of the spleen �% Examination of the spleen normally is not palpable if detected it means that the size is increased normally is not palpable if detected it means that the size is increased 1,5  3 times 1,5  3 times Massive Splenomegaly > 10 cm Massive Splenomegaly > 10 cm Differential diagnosis of splenomegaly Differential diagnosis of splenomegaly I Infections disease I Infections disease a. Bacterial: endocarditis tuberculosis, malaria, bacterial a. Bacterial: endocarditis tuberculosis, malaria, bacterial b. Viral : CMV,viral hepatitis b. Viral : CMV,viral hepatitis c. Parasitic: malaria, toxoplasmosis c. Parasitic: malaria, toxoplasmosis II Hemolytic anaemias II Hemolytic anaemias III Myeloproliferative-disorders : MF, CML,PV, TE, CEL III Myeloproliferative-disorders : MF, CML,PV, TE, CEL IV Lymphoproliferative: HCL,CLL, splenic lymphoma IV Lymphoproliferative: HCL,CLL, splenic lymphoma V Acute leukemias V Acute leukemias VI Storage diseases: Gaucher, Niemann-Pick disease, amyloidosis VI Storage diseases: Gaucher, Niemann-Pick disease, amyloidosis VII Portal vein obstruction: Budd-Chiarie VII Portal vein obstruction: Budd-Chiarie VIII Autoimmunological diseases: rheumatoid artritis, Felty`s syndrome VIII Autoimmunological diseases: rheumatoid artritis, Felty`s syndrome systemic lupus erythematosus systemic lupus erythematosus IX Others IX Others