HAEMATOLOGY PHYSICAL EXAMINATION GENERAL INSPECTION Position Lying down in supine position on bed inclined at 45 Sitting on bed Gait

ait Ataxia Ataxic gait Consciousness Alert Cooperative Confused Facial expression Respiratory distress Obvious pain Emotional distress Grooming Well groomed Well kempt Built Well built Well nourished Weight loss, cachexic, emaciated Malignancy Colour Pallor Anaemia Jaundice Haemolytic anaemia Gross deformity Gadgets Pulse oximeter Bp set IV drip O2 mask

HANDS Colour Pallor on palmar creases, nail bed Anaemia Jaundice Haemolytic anaemia Skin Rashes Infection Bleeding into skin

Excessive bruising Thrombocytopaenia BM depression in leukemia or aplastic anaemia Skin lesions Type Shape and margin Arrangement Distribution Glass test Scratch marks following pruritus Lymphoma Myeloproliferative disease Nails Koilonychia : dry, ridged, brittle nails IDA Clubbing IE Beaus lines : transverse lines or grooves on nail plate Systemic and local traumatic factors Connective tissue diseases Chronic inflammation leads to anaemia Rheumatoid arthiritis Feltys syndrome Neutropaenia Splenomegaly Rheumatoid arthritis THrombocytopaenia Haemolytic anaemia Skin pigmentation Leg ulcer Gouty tophi and arthropathy Myeloproliferative diseases Wristdrop Lead poisoning Pulse Tachycardia Anaemia reduced oxygen-carrying capacity of blood-increase cardiac outputcompensating tachycardia

ARMS Bp Hypertension Anaemia with CRF Hess test (refer Talley Pg 199) Thrombocytopaenia Joint swelling Haemarthroses in coagulation defect

Fracture and bone pain Patchy pain in myelom and metastatic tumour Generalsied pain in leukaemia Unilateral oedema Swollen lymph nodes obstruct veins and lympatics Arm oedema due to breast cancer Epitrochlear nodes (refer Talley pg 200) Enlargement Local infection Non-Hodgkins ly,phoma Syphilis

* Description of lymph nodes 1. Side 2. Type 3. Size 4. Site Localised Local infection Early lymphoma, esp Hodgkins disease Metastased from carcinoma Generalised Late lymphoma (rubbery and firm) Leukaemia, eg CML, ALL Infections Viral : infectious mononucleosis, CMV, HIV Bacterial : TB, brucellosis, syphilis Protozoal : Toxoplasmosis Connective tissue diseases, eg rheumatoid arthritis, SLE Infiltration, eg sarcoid Drugs, eg phenytoin (psudolymphoma) Abnormal : > 1cm Apitrochlear Axillary Cervical and occipital Supraclavicular Para aortic Inguinal Femoral Popliteal Left Right

5. Quantity Single Multiple Matted Infection Malignancy Tuberculous lymphadenopathy

6. Margin Well defined Ill defined

7. Surface Smooth Normal Rough Irregular Malignancy

8. Tenderness Tender zinfection Inflammation

9. Consistency Soft Normal Hard Carcinoma deposits Rubbery Lymphoma

10. Fixation Fixed to underlying structure Fixed : Likely to be infiltrated by carcinoma than mobile lymph nodes Mobile Benign

11. Overlying skin Inflammation of overlying skin Infection Tethering to overlying skin Carcinoma

AXILLA Inspection Discolouration of skin Visible or enlarged lump Swelling Surgical scar Sinus Abscess Rash , eg fungal rash Folliculitis Axillary nodes Central Anterior or pectoral Posterior or subscapular Lateral Apical Infraclavicular nodes

NECK

Inspection Discolouration of skin Visible or enlarged lump Swelling Scar Sinus Abscess Cervical and supraclavicular nodes Submental Submandibular Enlargement in dental infections Tonsillar/ jugolo-disgastric Enlargenment in URTI esp in children Preauricular Posterior auricular Occipital Posterior cervical/ Posterior triangle Superficial cervical/Anterior triangle Deep cervical Supraclavicular Small cervical nodes are often palpable in normal young people Cervical lympadenopathy may occur in tonsilitis

FACE Eyes Pallor on conjunctiva Jaundice on sclera Hemorrhage or injection : Increased prominence of sclera blood vessels Polycythemia Grey hair + blue eye in northern Europeans Lack of intrinsic factor secretion by atrophic gastric mucosa-vit B12 deficiencypernicious anaemia Mouth Angular stomatitis IDA Gum Hypertrophy in AML-M5-infiltration by leukaemic cells Swelling in scurvy Bleeding Ulceration, infection, haemorrhage of buccal and pharyngeal mucosa Tongue Pallor Jaundice on lingual frenulum Atrophic glossitis painless in IDA, painful in vit B12 deficiency Tonsils Tonsilitis (cervical lympadenopathy) Mucosa bleeding Thrombocytopaenia Marrow aplasia Infective lesions, eg thrush, candida Immunosupression Dental infections ( cervical lympadenopathy) Waldeyers ring : A circle of lymphatic tissue in posterior of oropharynx and nasopharynx Non-Hodgkins lymphoma

CHEST Bone tenderness Tender Enlarging marrow due to infiltration by myeloma, lymphoma, carcinoma OR due to malignancy of bony skeleton Heart sound Severe anaemia

ABDOMEN Spleen Splenomegaly Small CML, myelofibrosis, malaria, Kala azar, primary lymphoma of spleen, infection eg septicaemia, infectious mononucleosis, tb

Moderate- , portal HTN, lymphoma, leukaemia, thalassaemia, storage diseases eg. Gauchers disease, haemolytic anaemia, Massive , Myeloproliferative disorders eg polycythaemia rubra vera, essential thrombocytopaemia, haemolytic anaemia, megaloblastic anaemia, infection (viral: infectious mononucleosis, hepatitis,, bacterial : IE,, protozoal: malaria), connective tissue diseases eg rheumatoid arthritis, SLE, polyarteritis nodosa, infiltrations eg. amyloid, sarcoid, myelofibrosis, CML< thalassaemia, leishmaniasis May be found in 3-12% of normal population

Liver Hepatomegaly Hepatosplenomegaly CHF, chronic liver disease, lympho and myeloproliferative disorders, leuakemia eg AML, CML, lymphoma Para-aortic nodes Rarely palpable Enlarged : Felt as central deep abdominal mass Lymphoma Lymphatic leukaemia Inguinal nodes Small, firm, mobile nodes are commonly found in normal subjects Testicular masses Rectal examination Bleeding Carcinoma

LEGS Skin Rashes Infection Bleeding into skin Excessive bruising Thrombocytopaenia BM depression in leukemia or aplastic anaemia Skin lesions Type Shape and margin Arrangement Distribution Glass test Scratch marks following pruritus Joint swelling Haemarthroses in coagulation defect Fracture and bone pain Patchy pain in myelom and metastatic tumour Generalsied pain in leukaemia Ulcers above medial and lateral malleolus Haemaglobinopathies

Haemolytic anaemia, eg SCA, HS- abnormal blood viscosity-tissue infarction-leg ulcers Thalassaemia Macroglobulinaemia TTP Polycythaemia Feltys syndrome Popliteal nodes Foot drop Lead poisoning Neurological abnormalities Vit B12 deficiency-peripheral neuropathy