February 15th, 2021
Haematologic conditions such as leukaemia, lymphoma and the anaemias can be difficult to diagnose. The history is an important first step in this diagnosis, and provides information about the patient's baseline level of function prior to presentation.
Start by asking the patient what their main reason for presenting was.
- Common symptoms in haematologic disorders include:
- Constitutional symptoms - fatigue, lethargy, malaise, weight loss, night sweats
- Symptoms of anaemia - Fatigue, shortness of breath, reduced exercise tolerance, lightheadedness, worsening angina, ankle swelling
- Symptoms of neutropaenia - mouth ulcers, skin infections, other recurrent infections
- Symptoms of bleeding diathesis - easy bruising, epistaxis, gum bleeding, joint pain / swelling
- Symptoms of lymphoma - enlarged / painful lymph nodes, painful splenomegaly, B symptoms
- Symptoms of hyperviscosity - neuropathy, epistaxis, blurred vision, headache
- Symptoms of venous thromboembolism - limb pain / swalling, chest pain, shortness of breath, palpitations
Patients with haematologic disorders are often also referred in because they have abnormal blood tests; they may themselves be asymptomatic.
History of Presenting Complaint
When asking for more information about a patient's symptoms, start by asking general questions such as "could you please tell me more about that", and then narrow down the questions as more information is provided.
- Generally speaking, the following questions are a good starting point for any type of pain, and may be useful in gaining information about other symptoms:
- Site - localised or generalised; unilateral or bilateral
- Onset - sudden or gradual, and what the situation was (e.g. following trauma)
- Character - sharp, dull, burning or pressure-like
- Radiation - e.g. down the arm or across the back
- Associated symptoms - e.g. fevers, nausea / vomiting, bony pain
- Timing - duration of symptoms, frequency of episodes, changes through the day
- Exacerbating & alleviating factors - e.g. exacerbation with exertion and alleviation with rest
- Severity - on a scale of 1 to 10, with 10 being the worst
Past Medical History
Ask about any medical conditions the patient has previous been diagnosed with, the management of these conditions, and any complications they may have.
- Common haematologic disorders include:
- Haematologic malignancy - AML, ALL, CML, CLL, myeloma, lymphoma
- Myeloproliferative neoplasms - polycythaemia vera, essential thrombocytosis, myelofibrosis
- Myelodysplastic syndrome
- Anaemias - aplastic anaemia, iron deficiency Anaemia, anaemia of chronic disease, haemolytic anaemia, thalassaemias, sickle cell anaemia
- Bleeding disorders - haemophilias, Von Willebrand disease
- Thrombotic disorders - DVT / PE, antiphospholipid syndrome
- Platelet disorders - ITP, DIC, TTP, HUS, HELLP, HITS
Ask about a history of recurrent infections, which suggests immunosuppression and may occur in patients with neutropaenia.
Also ask about excessive bleeding or bruising in the past, which may be a symptom of platelet disorders or coagulopathy.
Ask about whether the patient has recieved any transfusions in the past, and whether they recieved red blood cells, platelets or plasma products.
Ask about any previous transfusion reactions (infectious or non-infectious), and whether the patient has any known antibodies.
Patients with certain haematologic disorders will have had an autologous or allogeneic stem cell transplant in the past.
An autologous stem cell transplant involves mobilising and collecting a patient's stem cells, providing chemotherapy to deplete the bone marrow, and then retransfusing their stem cells. This process is less complex and has less potential side effects than an allogeneic stem cell transplant.
An allogeneic stem cell transplant involves depleting a patient's bone marrow using chemotherapy, and then transfusing another (matched) patient's stem cells. This serves purposes of both replacing their haematopoietic cells with normal cells, and providing some degree of graft-vs-disease effect.
Ask about what medications the patient takes regularly, what they take them for, and what side effects they have had.
- A large number of drugs cause haematologic side effects. These include:
- Bleeding - NSAIDs, antiplatelets, SSRIs
- Thrombosis - oral contraceptives, hormone replacement, COX-2 inhibitors, erythropoietin, warfarin (initially)
- Anaemia - a large number of drugs may cause immune haemolysis, thrombotic microangiopathy, megaloblastic anaemia, sideroblastic anaemia, aplastic anaemia, pure red cell aplasia, or haemolysis in patients with G-6-PD deficiency
- Erythrocytosis - anaobolic steroids, erythropoietin
- Thrombocytopaenia - certain drugs may cause immune thrombocytopaenia, thrombotic microangiopathy or heparin-induced thrombocytopaenia
- Neutropaenia - NSAIDs, antipsychotics, anticonvulsants, antithyroid drugs, antibiotics, chemotherapy
- Neutrophilia - corticosteroids, adrenaline, lithium, G-CSF
- Eosinophilia - any cause of drug allergy; particularly penicillins, cephalosporins, phenytoin, carbamazepine, H2 blockers, PPIs
Ask about a family history of haematologic malignancy, such as AML, ALL, CML, CLL, myeloma or lymphoma.
Also ask about a family history of inherited haematologic disorders such as haemochromatosis, haemophilia, Von Willebrand's disease or thalassaemia.
It is important to understand any patient's social situation when taking their history. This includes key aspects such as their occupation (or previous occupation, if retired), living situation, mobility, ability to perform activities of daily living, diet and exercise.
In patients with suspected venous thromboembolism, ask about recent long-haul travel - particularly long flights.
Ask about alcohol intake, as alcohol abuse is associated with bone marrow suppression and myelodysplasia. Ask how many drinks the patient has per week, what type of drinks, and whether they have considered cutting down their intake if heavy.
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