The care of a patient with a suspected hematologic abnormality begins with a systematic attempt to determine the nature of the illness by eliciting an in-depth medical history and performing a thorough physical examination. The physician should identify the patient’s symptoms systematically and obtain as much relevant information as possible about their origin and evolution and about the general health of the patient by appropriate questions designed to explore the patient’s recent and remote experience. Reviewing previous records may add important data for understanding the onset or progression of illness. Hereditary and environmental factors should be carefully sought and evaluated. The use of drugs and medications, nutritional patterns, and sexual behavior should be considered. The physician should follow the medical history with a physical examination to obtain evidence for tissue and organ abnormalities that can be assessed through bedside observation to permit a careful search for signs of the illnesses suggested by the history. Skin changes and hepatic, splenic, or lymph nodal enlargement are a few findings that may be of considerable help in pointing toward a diagnosis. Additional history should be obtained during the physical examination, as findings suggest an additional or alternative consideration. Thus, the history and physical examination should be considered as a unit, providing the basic information with which further diagnostic information is integrated, with blood and marrow studies, imaging studies and tissue examination.
Primary hematologic diseases are common in the aggregate, but hematologic manifestations secondary to other diseases occur even more frequently. For example, the signs and symptoms of anemia and the presence of enlarged lymph nodes are common clinical findings that may be related to a hematologic disease, but which also occur frequently as secondary manifestations of disorders not considered primarily hematologic. A wide variety of diseases may produce signs or symptoms of hematologic illness. Thus, in patients with a connective tissue disease, all the signs and symptoms of anemia may be elicited and lymphadenopathy may be notable, but additional findings are usually present that indicate primary involvement of some system besides the hematopoietic (marrow) or lymphopoietic (lymph nodes or other lymphatic sites). In this discussion, emphasis is placed on the clinical findings resulting from either primary hematologic disease or the complications of hematologic disorders so as to avoid presenting an extensive catalog of signs and symptoms encountered in general clinical medicine.
In each discussion of specific diseases in subsequent chapters, the signs and symptoms that accompany the particular disorder are presented, and the clinical findings are covered in detail. This chapter takes a more general systematic approach.
THE HEMATOLOGY CONSULTATION
Table 1–1 lists the major abnormalities that result in the evaluation of the patient by the hematologist. The signs indicated in Table 1–1 may reflect a primary or secondary hematologic problem. For example, immature granulocytes in the blood may be signs of myeloid diseases such as myelogenous leukemia, or, depending on the frequency of these cells and ...