• Following points in history are essential in evaluation of patient who is suspected to have hematological disorders.
• Taking history as per the following format not only helps in the diagnosis of the condition, but also helps during management of patient.
• Hence, through history taking is absolutely essential, when patient is interacted for the first time.
• Before you start taking history, greet the patient and introduce yourself. Maintain privacy and make sure ambiance is good. 
• This chapter includes only important points which should not be missed while taking history and examining a patient with suspected hematological disorder. For detailed explanations one can refer separate books on clinical methods.

History taking:

Demographic details:  Name,Age and Sex of patient.

• Certain anemias such as –Alfa Thalassemia are seen at birth, while beta thalassemia is seen at around 5-6 months. If there is hemolytic anemia in elderly patient,it is because of acquired cause such as autoimmune hemolytic anemia.
• Hemophilia is usually seen in males.

Occupation

• People exposed to metal dusts,solvent fumes, lead and radiations are likely  to develop bone marrow suppression.
• Occupational history helps us to know the financial status, which is sometimes essential in planning the treatment of the patient.

Symptoms (Should note the duration and rate of onset of symptoms)

• First patient should be asked to narrate his complaints, following which leading questions should be asked to elicit history of symptoms which are mentioned below. 
• After examination and review of laboratory investigations,based on differential diagnosis additional history many be taken.

Fatigue

• It is a sign of anemia. Some patients express it in the form of weakness in limbs, dyspnea on exertion or giddiness. 

Fever

• Many hematological malignancies such as ALL,Hodgkin’s lymphoma, NHL can present with fever.
• In neutropenic patients, fever can be a sign of serious infection, which requires admission and administration of IV antibiotics.
• Some viral infections can cause pancytopenia due to bone marrow suppression

Bleeding

• It is an indication of thrombocytopenia, platelet dysfunction or coagulation disorder.
• Hemarthrosis and muscle hematomas are usually seen with defect in coagulation cascade.
• Purpura and mucosal bleeding suggest thrombocytopenia, platelet dysfunction or von Willebrand disease.
• Patient should be asked regarding bleeding from gums, epistaxis, PR bleed and malena.
• It also gives clue to the cause for repeated anemia.
• In patient with suspected bleeding disorder. History of  bleeding from umbilical stump, prolonged bleeding after trauma/ tooth extraction should be asked 

Jaundice

• Anemia with jaundice often suggests a diagnosis of hemolytic anemia.

Joint pain

• Presence of pain in small joints indicates presence of systemic autoimmune disease,such as SLE.
• Joint pain or bony pain can be a manifestation of ALL.

Weight loss, itching, night sweats (B symptoms)

• Presence of these symptoms favors the diagnosis of lymphoma.
• While planning treatment, this information is important. If B-symptoms are present, then patient needs to be given more cycles of chemotherapy.

Prior transfusions

• This indicates patient had severe anemia to begin with.
• Mismatched transfusion can be the cause of hemolysis
• Some tests such as hemoglobin electrophoresis cannot be done immediately after transfusions.
• After certain number of transfusions, chelation therapy is required.

Alternative medicines/ steroids

• These can induce transient remissions in patients with ALL. Also,one needs to monitor patient for development of tumor lysis syndrome.

Past history/co-morbidities (DM, HTN, CAD, TB, others)

• While giving steroids to diabetic patients, measures need to be taken to avoid hyperglycemia and ketoacidosis.
• Aspirin needs to be stopped if there is severe thrombocytopenia.
• If patient has significant co-morbidities, intense chemotherapies are avoided.
• Previous gastrectomy or bowel surgeries can lead to nutritional anemia.
• COPD/other lung disorders are associated with polycythemia.

Family history

• Diseases such as hemophilia, congenital hemolytic anemias run in families.
• Disorders such as autosomal recessive coagulation defects, platelet dysfunction disorders manifest in children born of consanguineous marriage.
• For bone marrow transplantation, one needs to know number of siblings and their ages.
• Hence it is better to draw a pedigree chart with inclusion of above details (Especially with age and disease)

Personal history

• Diet
  • Vegetarians are more prone to develop vitamin B12 deficiency.
• Appetite.
  • It is decreased in megaloblastic anemia and if there is underlying malignancy.
• Bowel and bladder habits.
  • Constipation or diarrhea can be side effects of chemotherapy.
  • Chronic diarrhea due to malabsorption syndrome can be associated with nutritional anemia.
  • Red colored urine indicates hematuria or hemoglobinuria.
• Habits
  • Alcoholism can lead to cirrhosis with congestive splenomegaly. This in turn can produce pancytopenia.
  • Alcohol and smoking can result in polycythemia.
• Menstrual history/obstetric history.
  • Menorrhagia can be due to thrombocytopenia or von willebrand disease. This can be a cause of iron deficiency anemia as well.(Menses up to 7 days with 2-3 days heavy flow can be considered normal. Presence of clots indicates heavy menstrual bleeding)
  • Recurrent abortions can be due to antiphospholipid antibody syndrome and afibrinogenemia.

Drug allergy

• If any drug allergies are present,this should be written on the top of patients’ file and these medications should never be administered.

Present medications

• Many of the medications have to be continued along with hematological disorder related treatment.
• Always one should write molecule name rather than the drug name.
• In certain situation some medicines need to be stopped. For example: In case of thrombocytopenia, aspirin needs to be stopped.
• Chronic NSAID or aspirin consumption can lead to iron deficiency because of bleeding from peptic ulcer.
• Anticonvulsants, zidovudine etc can produce macrocytic anemia.
• Methotrexate,linezolid, antiepileptics,antithyroid drugs,sulphonamides can produce bone marrow suppression and pancytopenia. With a careful history,many unnecessary bone marrow aspirations can be avoided.

Examination

Vitals

• These should be noted first, as unstable patients can be shifted to ICU without much delay, for further management.
• This must include
  • Temperature  (at least by noting by back of fingers)
  • Pulse
  • SPO2
  • Respiratory rate
  • Blood pressure
  • Consciousness.
• For stable patients following examination should be done.

Body surface area

• BSA (In m²)= 
• All Chemotherapy doses and IV fluid calculations are based on BSA.

Pallor

• This indicates anemia or peripheral vasoconstriction

Icterus

• It is present if there is significant hemolysis.

Cyanosis

• Methemoglobinemia patients have cyanosis.
• Cyanosis due to causes such as ventricular septal defect can have polycythemia.

Koilonychia/ platynychia

• It is a sign of iron deficiency anemia.

Lymphadenopathy

• Patients with lymphoma and ALL can have lymphadenopathy.
• Sites of lymphadenopathy have to be mentioned.

Edema, raised JVP

• It can be a sign of severe anemia with CCF.
• Unilateral edema is seen in case of DVT.

Hyperpigmented knuckles

• It is a sign of megaloblastic anemia.

Facies

• Patients with thalassemia have typical mangoloidfacies.

Sternal tenderness

• It is often present in patients with acute leukaemia.

Testis

• It must be always examined in patients with ALL, as management of testicular involvement needs few extra measures.

Oral cavity

• Angular cheilitis seen in iron deficiency anemia.
• Pallor can be noted in oral cavity as well
• Wet purpura indicates severe thrombocytopenia.
• Gum Bleeding/Hypertrophy- seen in acute leukemias.
• Bald, red tongue is suggestive of megaloblastic anemia.
• Black discoloration of tongue indicates dyskeratosis congenita
• Macroglossia is a feature of amyloidosis.
• Telangiectania around mouth is suggestive of hereditary hemorrhagic telangiectasia.

Skeletal abnormalities/ Stigmata of IBMFS (Commonly seen in congenital anemias such as Fanconi syndrome.)

• Short stature 
• Dysmorphic facial features 
• Thumb abnormalities 
• Café au lait spots

Performance score

• Knowing PS is very important in determining the intensity of chemotherapy as patients with poor PS cannot be offered intense chemotherapies.
• WHO performance scoring is as follows.
  • 0-Fully Active.
  • 1-Able to do light work.
  • 2-Able to do only self care.
  • 3-Bed bound for >50% of working hours.
  • 4-Totally confined to bed.
  • 5-Dead.
• Other methods of measurements include-karnovsky scale and Eastern co-operative oncology group scoring.

Respiratory system

• Note type and entry of breath sounds and any added sounds.
• If any abnormalities noted, chest X-Ray/CT chest can be done.

Cardiovascular system

• Hemic murmur may be heard in case of severe anemia.

Per-abdomen

• Look for splenomegaly and hepatomegaly,as they are associated with several benign and malignant hematological disorders.
• Look for stigmata of hepatic failure

Central nervous system

• Note consciousness, loss of movements in any part, pupils and plantar reflexes.
• If any abnormalities are found,do CT/MRI of brain and consult neurologist.

Local examination

• If patient has ulcer,swelling etc,local examination of that lesion has to be made.

Note:

• After completion of history taking and examination, previous investigations done (Lab and radiology)have to be noted. They give clue towards diagnosis and repetition of expensive tests can be avoided.
• After this, a list of differential diagnosis is made. Subsequent chapters are useful in preparing such a list. After this, appropriate investigations are ordered. Final diagnosis is made only after patient meets criteria for diagnosis for a particular disease.
• Based on provisional diagnosis, after counseling/ consent of patient/ relatives treatment has to be started. (Refer to “Supportive care drug sheet” on the last page of this book. After appropriate diagnostic sample is obtained, if clinically appropriate, may start steroids/ chemotherapy as well) 

(For the purpose of passing superspecialty exams, it is absolutely necessary to know full details of systemic examination and also joint examination for hemophilia case. For a long case, even if symptoms point towards a particular system, do examination of other systems as well)