HAEMATOLOGY & ONCOLOGY H+E:
Anaemia Anaemia Thrombocytopenia WBC Abnormality
• Fatigue Common signs Bruising • HIGH = leukeamia
• Ø Pale skin, conj. • Petechiae (pinhead red, non- • Low = leucopenia
SOB/dyspnoea,
Pallor, ↑HR, ↑RR bleeding flat spots) • Recurrent Infection (esp. URT):
Chest pain
Ø Confusion • Purpura ( > 5 mm) o pneumonia
Uncommon Sx:
Ø Koilonychia Bleeding: o Cold
Ø Restless leg
(spoon-shaped) o sinusitis
Ø Tinnitus Ø • Bleeding into joints
Angular cheilitis
Ø Pruritus (haemophilia) o HIV etc.
Ø Atrophic glossitis
Ø Hair loss (Fe def.
Ø Jaundice • Epistaxis • Subjective Fevers
anaemia)
Ø Mouth ulcers (Haemolytic • Mouth ulcers /blisters
Ø Vertigo anaemia)
• Unexplained constant Rash = leukaemia
Ø Pica (pregnancy- Ø Oedema, HTN and
History of
desire for non-food skin excoriations
presenting
e.g. dirt) (CKD)
complaint
Hodgkin’s Lymphoma Symptoms Of Myeloma (CRABS) Myeloproliferative disease
• Fever, UWL, NS, LN • HyperCalcium symptoms • PRV - RUDDY complexion, facial
(e.g. muscle weakness, plethora, splenomegaly
• Chronic fever (due to CMV or EBV - infectious polyuria, polydipsia, N+V, • ET = Vasomotor symptoms
mononucleosis) constipation, confusion) [microvascular] - SPHLECT
• Renal impairment,
• Male (bimodal 15-30s and > 55s) • Systemic (e.g. weight loss, fatigue,
• Anaemia è fatigue, chest fevers, sweats, pruritus)
• Pruritus after EtOH consumption pain
Non-Hodgkin’s Lymphoma • Bone pain/fractures
Ø Fever, UWL, NS, LN • SoBand palpitations
• anaemia related (rheumatoid arthritis or CKD), hepatitis and HIV status
Current Conditions
• Previous: haemophilia (coagulation), previous DVT, inherited clotting abnormality
• Fe supplements + VitB12 injection (anaemia), erythropoietin (CKD)
Medications
• Immunosuppressants (or. HIV) è increased risk of Hodgkin’s lymphoma
Past MHx
• chemotherapy for malignancy (leukaemia, myeloma or lymphoma or MDS)
Surgeries/Treatments • regular blood transfusions (MDS, myelofibrosis or bone marrow failure)
• Colonoscopy (possible anaemia due to polyps/bowel cancer/malabsorption)
Vaccinations • strep. Pneumoniae, FluVax)
• Thalassaemia (Mediterranean/South Asian)
Background
• sickle cell disease (Africans)
Social Hx
Occupation • toxin exposure (e.g. benzene ® risk of leukaemia)
Overseas travel • malarial infection or intestinal parasitic
• FHx of lymphoma = increased risk of lymphoma (esp. males > females for Hodgkin’s lymphoma)
• FHx of thalassaemia or sickle cell anaemia
Family Hx • FHx of Haemophilia (sex-linked recessive)
o Recombinant and donor-obtained factor IX concentrate is available for patients with haemophilia B
• von Willebrand’s disease (autosomal dominant + incomplete penetrance)
• Light-headed & Insomnia, anorexia, vision/hearing
Hyperviscosity Syndrome
• Back/joint pain/aches • Easy bruising Bone Marrow failure:
• Chest pain • Easy bleeding
• Anaemia ® pallor
SR • Cough • Reduced or loss of sight due to
• Thrombocytopenia ® bruise/bleed
vascular disease in the eye
• Bowel Habits (bowel cancer) • Leukopenia ® ulcers
• Purple discolouration to the
• Infiltrative (e.g. bone pain)
• Urination extremities (purplish palmar erythema)
• Metabolic effects (e.g. gingival)
• feeling cold? (hypothyroid) • Heart failure
•
RED FLAG DDx: DDx
1) Malignancy Specific Sx Cause
1o = myeloproliferative, Sepsis +NO fever Immuncomp (HIV,
lymphoproliferative, MDS, MM chemo, steroids,)
2O = Bone, breast, prostate, bowel Constitutional Sx Leukemia, lymphoma
2) Plt Issue / Coagulopathy Bleeding, bone pain, Solid-organ
ITP, VWF, Haemophilia, chronic liver lump malignancy
disease
Non-specific All cancer
Drug-induced (aspirin vs warfarin)
Fixed firm non-tender METS
Autoimmune (SLE) mass
3) Bone Marrow Suppression Key statistics: General Work-up
Chemo, RT 1) Biomarker – B-HCG, CA 19.9, CEA
• Prostate cancer (leading cancer cause) 2) Imaging – USS, XR, CT-PET, MRI
4) Acute Trauma • Breast cancer (leading female cancer) 3) Biopsy – solid organ, bone marrow
• Lung cancer (highest mortality cause)
, The Haematological Examination (Lymph node, liver, spleen)
POSTIOIN – LYING SUPINE AT 45o
1. Equipment, monitoring treatments (e.g. O2, nasogastric 7. Rash (lymphoma)
feeds, medications?) 8. Ulcers (neutropenia)
2. Vitals 9. Cyanosis and plethora (polycythaemia)
3. Weight 10. Jaundice (haemolytic anaemia)
General inspection 4. Cachexia 11. Scratch marks (myeloproliferative diseases, lymphoma)
5. Bruising (thrombocytopenia, scurvy) 12. Racial origin (thalassemia and sickle cell disease)
6. Pigmentation: Petechiae (pinhead bleeding), 13. Bone deformity (thalassemia)
Ecchymoses (large bruises), Pigmentation (lymphoma) 14. Oedema, HTN and excoriations of the skin (CKD)
• Koilonychia (Microcytic anaemia)
• Palmar crease pallor (anaemia – unreliable)
• Arthropathy
o haemophilia,
o gouty arthritis: (myeloproliferative disease)
Nails/Palms o drug treatment
o RA
• Pulse (tachycardia to compensate– anaemia = low O2
carrying capacity)
• Digital infarction (abnormal globulins – cryoglobulinemia)
• Gout & arthropathy (SLE) DDx: BB, scleroderma, perniosis | DDx: cryoglobulinemia, IE
Bruising (e.g. purpura, petechiae)
• Petechiae (pinhead red, non-bleeding flat spots) ®
bleed into skin
o Leukaemia
o Meningococcal septicaemia
o Vasculitis
o HSP
o ITP
o NAI
• Purpura ( > 5 mm): LYMPHADENOPATHY:
o Trauma
• Size: Large nodes (> 1 cm = abnormal).
o Vasculitis (HSP)
• Consistency: Hard = tumour, soft = normal, rubbery = lymphoma.
o Thrombocytopenia
o platelet dysfunction (CKD), • Tenderness: infection or acute inflammation.
o if raised = palpable purpura (NOT • Fixation: fixed nodes more likely than mobile nodes to be infiltrated by carcinoma.
thrombocytopenia but systemic vasculitis and • Inflammation over Overlying skin: ® infection, and tethering to overlying skin ®
possibly tender) carcinoma.
o Senile ecchymoses/bruises • benign = lipoma, abscess, sebaceous cyst
o Coagulation disorders
§ Acquired (Vit k deficiency, liver
1=submental;
disease, DIC, anticoagulants)
2=submandibular;
§ Congenital (haemophilia A/B) • Head and neck cancer
3=jugular chain
• Bleeding into joints (haemophilia) • Lymphoma
4=supraclavicular [shrug
Cervical shoulders] ; • 2nd mets: Tap for bony
tenderness (in spine,
5=posterior triangle;
6=postauricular; sternum, clavicles,
7=preauricular; shoulders)
8=occipital
Supra- R supraclav Oesophageal cancer
clavicular L supraclav Abdo cancer (e.g. troisier’s sign)
• central,
Arms/Axilla • lateral (above and latera) Ø Upper limb infections
Ø Breast Cancer
Axillary • pectoral (medial)
Ø 2nd mets
(C-LPIS) • infraclavicular Ø Immunisations
• subscapular (most Ø Lymphoma
inferior)
Ask patient to flex elbow at 90o
Ø Arm infection
and abduct upper arm a little
Epitrochlear Ø Lymphoma
and place palm of hand under
Ø sarcoidosis
elbow
Ø Lower limb infections
Ø STD
Inguinal Ø Abdo/pelvic cancer
Ø Immunisations
Ø Lymphoma
*KEY Differentials of enlarged LN
• Infection (most common) e.g. cellulitis
• reactive immune response
• autoimmune (e.g. thyroid nodule)
• malignancy (least common)
• benign = lipoma, abscess, sebaceous cyst
, • Sclera —jaundice [scleral icterus], conjunctival pallor,
polycythaemia rubra vera (i.e. prominent scleral BVs since bone
marrow overproduces RBCs)
• EPISTAXIS - anti-coag, anti-plt, trauma, mucosal oral bleeds
Face /eyes /mouth
• Mouth : gum hypertrophy (monocytic leukaemia), mouth
ulcers, , angular chelitis stomatitis (Fe, vitamin deficiencies)
• Tongue —amyloidosis, atrophic glossitis (anaemia)
1. Apex beat + murmurs
Chest
2. Bony tenderness = sternum, spine, RIB, clavicle
1. GI = distensions, scars and prominent veins
2. Palpate for: While patient under full inspiration
o Hepatomegaly (RIF ® RUQ)
o Splenomegaly (RIF ® LUQ)
o Para-aortic lymph nodes (rarely palpable)
o inguinal lymph nodes (i.e. along inguinal ligament +
along the femoral vessels) ® lymphangitis
3. Percuss for:
o Ascites
o Traube space = dull (if splenomegaly) è patient
supine ® abduct the patient’s left arm slightly ®
breath normally ® percuss across the space from its medial to lateral margins
o Castell spot: dull in inspiration (if splenomegaly) è patient supine ® percuss castell spot (lowest left intercostal space in the
anterior axillary line—with the patient in full inspiration and expiration.
4. Auscultation – SBO/LBO (bruits and rubs), RAS (murmur)
Abdomen & genitalia
Hepatomegaly Splenomegaly (CHINA-man)
Ø Congestive (cirrhosis, CCF, budd-chiari) Ø Congestion (portal HTN - Chronic liver disease)
Ø Infection (bacterial cholangitis, hep A/B/C, malaria, black fever, Ø Haematological (AHA, sickle cell)
schistosomiasis, histoplasmosis, TB infection, liver abscess -amoebiasis) Ø Infection (malaria, EBV, TB, leishmaniasis, black fever,
Ø Infiltrative brucellosis – Mediterranean fever)
o Malignant (Mets, primary HCC, polycythaemia, MM, lymphoma) Ø Neoplasm = Myeloproliferative (CML, myelofibrosis)
o Non-malignant (cyst, Wilson, amyloidosis, myelofibrosis) + lymphoma
Ø Inflammatory (alcoholic, autoimmune, drug-induced, sarcoidosis) Ø Autoimmune (RA, sarcoid, amyloid)
Ø MASSIVE SM = malaria, myelofibrosis, CML
• Petechiae/ Leg ulcers (thalassemia, TTP, Polycythaemia, SICKLE CELL anemia) ® look for signs of DVT
• Rash = Vasculitis (Henoch–Schönlein purpura— buttocks, thighs)
• Bruising + Pigmentation (due to drugs?)
o Anti-coag (DOAC, warfarin, LMWH)
Legs
• Ulceration (e.g. haemoglobinopathies)
• Arthropathies (gout, arthralgia)
• Neurological signs (subacute combined degeneration, peripheral neuropathy due to Vit B12 deficiency)
o Foot drop (due to lead poisoning causing aneamia)
• Genital, Rectal and pelvic examination (for • Urine analysis (haematuria, bile, etc.)
tumour and bleeding) • Urine M/C/S
• Fundoscopy (haemorrhages, infection, optic • Bloods (FBC, Blood film, EUC, LFT, CRP)
Requests atrophy due to Vit B12 deficiency , increased blood • CXR
viscosity -macroglobulinemia)
• LN biopsy
• Temperature chart (infection)
• Bone marrow biopsy – POSTERIOR ILIAC CREST = NO BV/NERVES
Submandibular
lymphadenopathy
Ø SC compression
Ø SVC obstruction
RADIOTHERAPY
INDICATIONS Cervical lymphadenopathy
Anaemia Anaemia Thrombocytopenia WBC Abnormality
• Fatigue Common signs Bruising • HIGH = leukeamia
• Ø Pale skin, conj. • Petechiae (pinhead red, non- • Low = leucopenia
SOB/dyspnoea,
Pallor, ↑HR, ↑RR bleeding flat spots) • Recurrent Infection (esp. URT):
Chest pain
Ø Confusion • Purpura ( > 5 mm) o pneumonia
Uncommon Sx:
Ø Koilonychia Bleeding: o Cold
Ø Restless leg
(spoon-shaped) o sinusitis
Ø Tinnitus Ø • Bleeding into joints
Angular cheilitis
Ø Pruritus (haemophilia) o HIV etc.
Ø Atrophic glossitis
Ø Hair loss (Fe def.
Ø Jaundice • Epistaxis • Subjective Fevers
anaemia)
Ø Mouth ulcers (Haemolytic • Mouth ulcers /blisters
Ø Vertigo anaemia)
• Unexplained constant Rash = leukaemia
Ø Pica (pregnancy- Ø Oedema, HTN and
History of
desire for non-food skin excoriations
presenting
e.g. dirt) (CKD)
complaint
Hodgkin’s Lymphoma Symptoms Of Myeloma (CRABS) Myeloproliferative disease
• Fever, UWL, NS, LN • HyperCalcium symptoms • PRV - RUDDY complexion, facial
(e.g. muscle weakness, plethora, splenomegaly
• Chronic fever (due to CMV or EBV - infectious polyuria, polydipsia, N+V, • ET = Vasomotor symptoms
mononucleosis) constipation, confusion) [microvascular] - SPHLECT
• Renal impairment,
• Male (bimodal 15-30s and > 55s) • Systemic (e.g. weight loss, fatigue,
• Anaemia è fatigue, chest fevers, sweats, pruritus)
• Pruritus after EtOH consumption pain
Non-Hodgkin’s Lymphoma • Bone pain/fractures
Ø Fever, UWL, NS, LN • SoBand palpitations
• anaemia related (rheumatoid arthritis or CKD), hepatitis and HIV status
Current Conditions
• Previous: haemophilia (coagulation), previous DVT, inherited clotting abnormality
• Fe supplements + VitB12 injection (anaemia), erythropoietin (CKD)
Medications
• Immunosuppressants (or. HIV) è increased risk of Hodgkin’s lymphoma
Past MHx
• chemotherapy for malignancy (leukaemia, myeloma or lymphoma or MDS)
Surgeries/Treatments • regular blood transfusions (MDS, myelofibrosis or bone marrow failure)
• Colonoscopy (possible anaemia due to polyps/bowel cancer/malabsorption)
Vaccinations • strep. Pneumoniae, FluVax)
• Thalassaemia (Mediterranean/South Asian)
Background
• sickle cell disease (Africans)
Social Hx
Occupation • toxin exposure (e.g. benzene ® risk of leukaemia)
Overseas travel • malarial infection or intestinal parasitic
• FHx of lymphoma = increased risk of lymphoma (esp. males > females for Hodgkin’s lymphoma)
• FHx of thalassaemia or sickle cell anaemia
Family Hx • FHx of Haemophilia (sex-linked recessive)
o Recombinant and donor-obtained factor IX concentrate is available for patients with haemophilia B
• von Willebrand’s disease (autosomal dominant + incomplete penetrance)
• Light-headed & Insomnia, anorexia, vision/hearing
Hyperviscosity Syndrome
• Back/joint pain/aches • Easy bruising Bone Marrow failure:
• Chest pain • Easy bleeding
• Anaemia ® pallor
SR • Cough • Reduced or loss of sight due to
• Thrombocytopenia ® bruise/bleed
vascular disease in the eye
• Bowel Habits (bowel cancer) • Leukopenia ® ulcers
• Purple discolouration to the
• Infiltrative (e.g. bone pain)
• Urination extremities (purplish palmar erythema)
• Metabolic effects (e.g. gingival)
• feeling cold? (hypothyroid) • Heart failure
•
RED FLAG DDx: DDx
1) Malignancy Specific Sx Cause
1o = myeloproliferative, Sepsis +NO fever Immuncomp (HIV,
lymphoproliferative, MDS, MM chemo, steroids,)
2O = Bone, breast, prostate, bowel Constitutional Sx Leukemia, lymphoma
2) Plt Issue / Coagulopathy Bleeding, bone pain, Solid-organ
ITP, VWF, Haemophilia, chronic liver lump malignancy
disease
Non-specific All cancer
Drug-induced (aspirin vs warfarin)
Fixed firm non-tender METS
Autoimmune (SLE) mass
3) Bone Marrow Suppression Key statistics: General Work-up
Chemo, RT 1) Biomarker – B-HCG, CA 19.9, CEA
• Prostate cancer (leading cancer cause) 2) Imaging – USS, XR, CT-PET, MRI
4) Acute Trauma • Breast cancer (leading female cancer) 3) Biopsy – solid organ, bone marrow
• Lung cancer (highest mortality cause)
, The Haematological Examination (Lymph node, liver, spleen)
POSTIOIN – LYING SUPINE AT 45o
1. Equipment, monitoring treatments (e.g. O2, nasogastric 7. Rash (lymphoma)
feeds, medications?) 8. Ulcers (neutropenia)
2. Vitals 9. Cyanosis and plethora (polycythaemia)
3. Weight 10. Jaundice (haemolytic anaemia)
General inspection 4. Cachexia 11. Scratch marks (myeloproliferative diseases, lymphoma)
5. Bruising (thrombocytopenia, scurvy) 12. Racial origin (thalassemia and sickle cell disease)
6. Pigmentation: Petechiae (pinhead bleeding), 13. Bone deformity (thalassemia)
Ecchymoses (large bruises), Pigmentation (lymphoma) 14. Oedema, HTN and excoriations of the skin (CKD)
• Koilonychia (Microcytic anaemia)
• Palmar crease pallor (anaemia – unreliable)
• Arthropathy
o haemophilia,
o gouty arthritis: (myeloproliferative disease)
Nails/Palms o drug treatment
o RA
• Pulse (tachycardia to compensate– anaemia = low O2
carrying capacity)
• Digital infarction (abnormal globulins – cryoglobulinemia)
• Gout & arthropathy (SLE) DDx: BB, scleroderma, perniosis | DDx: cryoglobulinemia, IE
Bruising (e.g. purpura, petechiae)
• Petechiae (pinhead red, non-bleeding flat spots) ®
bleed into skin
o Leukaemia
o Meningococcal septicaemia
o Vasculitis
o HSP
o ITP
o NAI
• Purpura ( > 5 mm): LYMPHADENOPATHY:
o Trauma
• Size: Large nodes (> 1 cm = abnormal).
o Vasculitis (HSP)
• Consistency: Hard = tumour, soft = normal, rubbery = lymphoma.
o Thrombocytopenia
o platelet dysfunction (CKD), • Tenderness: infection or acute inflammation.
o if raised = palpable purpura (NOT • Fixation: fixed nodes more likely than mobile nodes to be infiltrated by carcinoma.
thrombocytopenia but systemic vasculitis and • Inflammation over Overlying skin: ® infection, and tethering to overlying skin ®
possibly tender) carcinoma.
o Senile ecchymoses/bruises • benign = lipoma, abscess, sebaceous cyst
o Coagulation disorders
§ Acquired (Vit k deficiency, liver
1=submental;
disease, DIC, anticoagulants)
2=submandibular;
§ Congenital (haemophilia A/B) • Head and neck cancer
3=jugular chain
• Bleeding into joints (haemophilia) • Lymphoma
4=supraclavicular [shrug
Cervical shoulders] ; • 2nd mets: Tap for bony
tenderness (in spine,
5=posterior triangle;
6=postauricular; sternum, clavicles,
7=preauricular; shoulders)
8=occipital
Supra- R supraclav Oesophageal cancer
clavicular L supraclav Abdo cancer (e.g. troisier’s sign)
• central,
Arms/Axilla • lateral (above and latera) Ø Upper limb infections
Ø Breast Cancer
Axillary • pectoral (medial)
Ø 2nd mets
(C-LPIS) • infraclavicular Ø Immunisations
• subscapular (most Ø Lymphoma
inferior)
Ask patient to flex elbow at 90o
Ø Arm infection
and abduct upper arm a little
Epitrochlear Ø Lymphoma
and place palm of hand under
Ø sarcoidosis
elbow
Ø Lower limb infections
Ø STD
Inguinal Ø Abdo/pelvic cancer
Ø Immunisations
Ø Lymphoma
*KEY Differentials of enlarged LN
• Infection (most common) e.g. cellulitis
• reactive immune response
• autoimmune (e.g. thyroid nodule)
• malignancy (least common)
• benign = lipoma, abscess, sebaceous cyst
, • Sclera —jaundice [scleral icterus], conjunctival pallor,
polycythaemia rubra vera (i.e. prominent scleral BVs since bone
marrow overproduces RBCs)
• EPISTAXIS - anti-coag, anti-plt, trauma, mucosal oral bleeds
Face /eyes /mouth
• Mouth : gum hypertrophy (monocytic leukaemia), mouth
ulcers, , angular chelitis stomatitis (Fe, vitamin deficiencies)
• Tongue —amyloidosis, atrophic glossitis (anaemia)
1. Apex beat + murmurs
Chest
2. Bony tenderness = sternum, spine, RIB, clavicle
1. GI = distensions, scars and prominent veins
2. Palpate for: While patient under full inspiration
o Hepatomegaly (RIF ® RUQ)
o Splenomegaly (RIF ® LUQ)
o Para-aortic lymph nodes (rarely palpable)
o inguinal lymph nodes (i.e. along inguinal ligament +
along the femoral vessels) ® lymphangitis
3. Percuss for:
o Ascites
o Traube space = dull (if splenomegaly) è patient
supine ® abduct the patient’s left arm slightly ®
breath normally ® percuss across the space from its medial to lateral margins
o Castell spot: dull in inspiration (if splenomegaly) è patient supine ® percuss castell spot (lowest left intercostal space in the
anterior axillary line—with the patient in full inspiration and expiration.
4. Auscultation – SBO/LBO (bruits and rubs), RAS (murmur)
Abdomen & genitalia
Hepatomegaly Splenomegaly (CHINA-man)
Ø Congestive (cirrhosis, CCF, budd-chiari) Ø Congestion (portal HTN - Chronic liver disease)
Ø Infection (bacterial cholangitis, hep A/B/C, malaria, black fever, Ø Haematological (AHA, sickle cell)
schistosomiasis, histoplasmosis, TB infection, liver abscess -amoebiasis) Ø Infection (malaria, EBV, TB, leishmaniasis, black fever,
Ø Infiltrative brucellosis – Mediterranean fever)
o Malignant (Mets, primary HCC, polycythaemia, MM, lymphoma) Ø Neoplasm = Myeloproliferative (CML, myelofibrosis)
o Non-malignant (cyst, Wilson, amyloidosis, myelofibrosis) + lymphoma
Ø Inflammatory (alcoholic, autoimmune, drug-induced, sarcoidosis) Ø Autoimmune (RA, sarcoid, amyloid)
Ø MASSIVE SM = malaria, myelofibrosis, CML
• Petechiae/ Leg ulcers (thalassemia, TTP, Polycythaemia, SICKLE CELL anemia) ® look for signs of DVT
• Rash = Vasculitis (Henoch–Schönlein purpura— buttocks, thighs)
• Bruising + Pigmentation (due to drugs?)
o Anti-coag (DOAC, warfarin, LMWH)
Legs
• Ulceration (e.g. haemoglobinopathies)
• Arthropathies (gout, arthralgia)
• Neurological signs (subacute combined degeneration, peripheral neuropathy due to Vit B12 deficiency)
o Foot drop (due to lead poisoning causing aneamia)
• Genital, Rectal and pelvic examination (for • Urine analysis (haematuria, bile, etc.)
tumour and bleeding) • Urine M/C/S
• Fundoscopy (haemorrhages, infection, optic • Bloods (FBC, Blood film, EUC, LFT, CRP)
Requests atrophy due to Vit B12 deficiency , increased blood • CXR
viscosity -macroglobulinemia)
• LN biopsy
• Temperature chart (infection)
• Bone marrow biopsy – POSTERIOR ILIAC CREST = NO BV/NERVES
Submandibular
lymphadenopathy
Ø SC compression
Ø SVC obstruction
RADIOTHERAPY
INDICATIONS Cervical lymphadenopathy
