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 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 follows the medical
history with a physical examination to obtain evidence for tissue and
organ abnormalities that can be accessed 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 is 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: blood and marrow studies
and imaging studies and biopsies.
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 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. In this
chapter a more general systematic approach is taken.
Acronyms and Abbreviations
Acronyms and abbreviations
that appear in this chapter include: HELLP syndrome, hemolytic anemia,
elevated liver enzymes, and low platelet count; Ig, immunoglobulin;
IL, interleukin; POEMS, polyneuropathy, organomegaly, endocrinopathy,
monoclonal gammopathy, and skin changes; PS, performance status.
Table 1–1 lists the major abnormalities
that result in the evaluation of the patient by the hematologist.
The signs indicated in Table ...