Haematology: History and Examination

🩺 Haematology history and examination -blood disorders show themselves in a small number of ways: tiredness and pallor (anaemia), bleeding and bruising (platelets or clotting), infections (white cells), clots, and lumps (lymph nodes, spleen, liver). A careful history and a focused examination -hands, eyes, mouth, skin, nodes, spleen, bones -usually tells you which cell line is affected and how urgently the patient needs help. The full blood count and blood film then confirm it.
Your four questions for every patient: Which cell line is affected -red cells, white cells, platelets, clotting, or more than one? Is this dangerous right now (bleeding, sepsis, very high white count, cord compression)? Is it a deficiency, destruction, marrow failure, or a cancer? What drugs, family history or background explain it?

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Approach to the Haematology History

• Introduce yourself, confirm identity, gain consent, and start with open questions ("Tell me what's been happening").
• Presenting complaint -in the patient's words. Many haematology patients come with an abnormal blood test rather than a symptom -ask why the test was done and look at previous results (a trend matters more than a single value).
• History of presenting complaint -explore the main symptom, then screen for the key haematology symptoms:
  • Tiredness, breathlessness, palpitations, dizziness (anaemia).
  • Bleeding -bruising, nosebleeds, gum bleeding, heavy periods, blood in urine or stool.
  • Infections -how often, how severe, unusual organisms, mouth ulcers.
  • Lumps -neck, armpits, groin; abdominal fullness or early satiety (big spleen).
  • B symptoms -fevers, drenching night sweats, weight loss over 10% in 6 months.
  • Bone pain, itch, headache or visual blurring (thick blood), clots.
• Timeline -sudden (bleeding, haemolysis, acute leukaemia) or gradual over months (iron or B12 deficiency, chronic leukaemia, myeloma).
• Past medical, drug, family and social history -especially drugs (many blood problems are drug-induced), ethnicity and family history (haemoglobinopathies, bleeding disorders, G6PD), diet and alcohol, transfusion and pregnancy history.
• Ideas, concerns and expectations -patients often fear leukaemia or cancer when told their blood test is abnormal -ask, and explain what happens next.
• Summarise back to the patient and check you've understood.

Tiredness and Symptoms of Anaemia

• Symptoms depend on speed -a slow fall in haemoglobin is well tolerated (the body adapts); a rapid fall (bleeding, haemolysis) causes symptoms at higher levels. Older people and those with heart or lung disease become symptomatic sooner.
• General symptoms -tiredness, lack of energy, poor concentration, headache, breathlessness on exertion, palpitations, dizziness, fainting.
• Symptoms that suggest severity -angina, breathlessness at rest, heart failure (ankle swelling, orthopnoea), worsening claudication, confusion in older people, collapse.
• Clues to the cause:
  • Blood loss -heavy periods (number of days, flooding, clots, changing pads or tampons hourly, double protection), black tarry stools (melaena), fresh rectal bleeding, change in bowel habit, indigestion, NSAID or aspirin use, anticoagulants, haematuria, frequent blood donation.
  • Poor intake or absorption -vegetarian or vegan diet, restrictive eating, coeliac symptoms (diarrhoea, bloating, weight loss), previous gastric or bowel surgery, PPIs, metformin.
  • Haemolysis -jaundice, dark urine (especially first thing in the morning in PNH, or after a trigger), gallstones at a young age, recent new drugs, infections or fava beans (G6PD), symptoms in the cold (cold agglutinins), recent transfusion.
  • B12 deficiency -pins and needles, numbness, unsteadiness, memory problems, sore red tongue, mouth ulcers; autoimmune disease (thyroid, vitiligo, type 1 diabetes).
  • Chronic disease -rheumatoid arthritis, IBD, CKD, chronic infection, cancer.
  • Marrow failure -infections and bleeding as well as anaemia.
  • Pica -craving ice (pagophagia), soil or starch -a classic clue to iron deficiency.
• Restless legs, hair loss and brittle nails can also come from iron deficiency, even before anaemia develops.

Bleeding and Bruising

• Key questions:
  • Where? Skin, nose, gums, gut, urine, periods, joints, muscles, after procedures.
  • How much? Did bleeding need treatment -packing, cautery, transfusion, iron, return to theatre?
  • Spontaneous or after injury? Out of proportion to the injury?
  • Since when? Lifelong (inherited -since childhood, after circumcision, tooth extractions, tonsillectomy) or new (acquired -drugs, liver disease, leukaemia, ITP, acquired haemophilia).
  • Immediate or delayed? Bleeding straight after a cut or procedure suggests platelets or von Willebrand factor; bleeding that starts again hours later suggests a clotting factor problem.
• Ask specifically about:
  • Nosebleeds -lasting over 10 minutes, both nostrils, needing medical care.
  • Heavy periods since the first period (common in von Willebrand disease); postpartum haemorrhage.
  • Dental extractions -prolonged oozing, return to dentist.
  • Surgery -previous operations without bleeding are reassuring (a "natural stress test").
  • Joint and muscle bleeds -painful swollen joints after minor knocks (haemophilia).
  • Easy bruising -large bruises (bigger than a 50p coin) from unnoticed knocks, on the trunk as well as the limbs.
• Structured bleeding scores (e.g. the ISTH bleeding assessment tool) help judge whether bleeding is abnormal -many healthy people report some bruising or nosebleeds.
• Drugs -anticoagulants, antiplatelets, NSAIDs, SSRIs, steroids (skin bruising), herbal products (ginkgo, fish oil, garlic in large amounts).
• Other clues -liver disease (alcohol), kidney disease (uraemic bleeding), recent infection (ITP in children), fever and confusion (TTP), sepsis (DIC), pregnancy (HELLP), malabsorption (vitamin K), poor diet (scurvy -gum bleeding, perifollicular haemorrhages, corkscrew hairs).
• Unexplained bruising in a child -consider non-accidental injury as well as blood disorders (pattern, site, history consistent with development) -follow safeguarding procedures.

Clots

• DVT -one-sided leg swelling, pain, warmth, redness; PE -sudden breathlessness, pleuritic chest pain, haemoptysis, collapse.
• Was it provoked?
  • Major provoking factors -surgery, trauma, immobility (hospital stay, plaster cast), long-haul travel, pregnancy and the postpartum period.
  • Minor or ongoing factors -combined pill or oral HRT, cancer and its treatment, obesity, inflammatory disease (IBD), nephrotic syndrome, recent infection (including COVID-19).
  • Unprovoked -ask about symptoms of cancer (weight loss, bleeding, change in bowel habit, cough) and examine carefully.
• Unusual features that suggest an underlying blood disorder:
  • Clots at a young age, recurrent clots, a strong family history.
  • Clots in unusual sites -brain venous sinuses, liver (Budd–Chiari), portal or mesenteric veins → think myeloproliferative neoplasm (JAK2), PNH, antiphospholipid syndrome, cancer.
  • Arterial and venous clots together, or with pregnancy loss → antiphospholipid syndrome.
  • Clots with falling platelets on heparin → HIT.
  • Clots with high haemoglobin, itch after bathing or burning red hands and feet → polycythaemia vera or essential thrombocythaemia.
• Previous treatment -which anticoagulant, how long, any bleeding on it, and whether clots recurred during treatment.

Infections and Fever

• Ask about -frequency and severity (hospital admissions, IV antibiotics), sites (chest, skin, mouth, urine, sinuses), unusual or opportunistic infections (fungal, shingles in more than one area, PCP).
• Patterns:
  • Neutropenia -mouth ulcers, sore throat, skin and chest infections, perianal infection, sepsis without obvious source; signs of infection may be minimal (no pus without neutrophils).
  • Low antibodies (CLL, myeloma, after rituximab) -repeated chest and sinus infections with bacteria (pneumococcus, Haemophilus), bronchiectasis.
  • T-cell problems (steroids, fludarabine, HIV) -viruses (shingles, CMV), PCP, fungi, TB.
  • Hyposplenism -overwhelming infection with encapsulated bacteria.
• Recent chemotherapy -any patient who has had chemotherapy in the last 6 weeks and feels unwell or has a fever has neutropenic sepsis until proven otherwise -antibiotics within 1 hour.
• Fever in a haematology patient may also be from the disease itself (lymphoma, leukaemia), transfusion reactions or drugs.
• Travel -malaria (anaemia, low platelets, splenomegaly, jaundice), visceral leishmaniasis, TB, HIV; ask about antimalarial use.
• Recent infections can cause blood changes -EBV (atypical lymphocytes, splenomegaly, low platelets, haemolysis), parvovirus (red cell aplasia in haemolytic anaemias), Mycoplasma (cold agglutinins), HIV and hepatitis C (low platelets).

Lumps, Night Sweats and Weight Loss

• Lumps -where, how long, growing or shrinking, painful or painless, single or several; recent sore throat, dental or skin infection, cat scratches, sexual history, TB contact.
• Features suggesting lymphoma or cancer -painless, rubbery or hard, enlarging nodes, larger than about 2 cm, lasting over 6 weeks, supraclavicular, generalised, with B symptoms.
• B symptoms (important in lymphoma staging):
  • Fevers over 38°C without infection.
  • Drenching night sweats (needing to change clothes or bedding).
  • Unintentional weight loss over 10% in 6 months.
• Other lymphoma clues -itch (generalised, often severe -Hodgkin's), pain in nodes after alcohol (Hodgkin's, rare but classic), cough or breathlessness (mediastinal mass), facial swelling and distended neck veins (superior vena cava obstruction), abdominal fullness.
• Big spleen symptoms -early fullness after small meals, left upper abdominal discomfort or dragging, pain referred to the left shoulder (splenic infarct).
• Age and epidemiology -Hodgkin's peaks in young adults and older adults; CLL and myeloma mostly over 60; acute lymphoblastic leukaemia mainly in children; HIV increases lymphoma risk.

Bone Pain and Other Symptoms

• Bone pain:
  • Myeloma -persistent back pain or rib pain, especially in people over 60, worse at night or on movement; fractures with minimal trauma.
  • Sickle cell crisis -severe pain in back, chest, limbs, often with known triggers.
  • Acute leukaemia -bone pain in children (limping, refusing to walk).
  • G-CSF treatment causes bone pain.
• "CRAB" symptoms of myeloma -Calcium (thirst, polyuria, constipation, confusion, abdominal pain), Renal (reduced urine, oedema), Anaemia (tiredness), Bone (pain, fractures); plus recurrent infections.
• Hyperviscosity (very high paraprotein -Waldenström's, myeloma; very high white count; polycythaemia) -headache, blurred vision, confusion, drowsiness, nosebleeds, breathlessness, stroke-like symptoms.
• Polycythaemia and myeloproliferative symptoms -itch after a warm bath or shower (aquagenic pruritus), burning red painful fingers and toes (erythromelalgia -responds to aspirin), headache, plethora, gout, sweats.
• Neurological symptoms -numbness and unsteadiness (B12 deficiency, myeloma or paraprotein neuropathy, chemotherapy); back pain with leg weakness, numbness or bladder problems (spinal cord compression -myeloma, lymphoma); headache with confusion (CNS lymphoma or leukaemia, bleeding).
• Skin and mouth -mouth ulcers (neutropenia), gum swelling (monocytic AML), sore tongue and cracked mouth corners (iron or B12 deficiency), new rashes (leukaemia cutis, graft-versus-host disease).
• Dark urine -haemoglobinuria (intravascular haemolysis) versus bilirubin (obstructive jaundice) -ask about stool colour and itch.
• Gout and kidney stones -high cell turnover (myeloproliferative disorders, leukaemia, haemolysis).

Past, Drug, Family and Social History

• Past medical history:
  • Previous blood problems, blood tests, iron or B12 treatment, transfusions (when, why, any reactions -antibodies may complicate future transfusions).
  • Splenectomy (and vaccinations), gastric or bowel surgery, coeliac disease, IBD.
  • Liver, kidney, thyroid and autoimmune disease; previous cancer, chemotherapy or radiotherapy (secondary leukaemia, myelodysplasia).
  • Pregnancies -miscarriages (antiphospholipid syndrome), postpartum haemorrhage, anti-D, babies with jaundice or anaemia.
  • Previous clots or bleeding with surgery, dental work or childbirth.
• Drug history -always ask about over-the-counter and herbal medicines and recent courses:
  • Bleeding -anticoagulants, antiplatelets, NSAIDs, SSRIs, steroids.
  • Low counts -carbimazole, clozapine, sulfasalazine, methotrexate, azathioprine, chemotherapy, co-trimoxazole, antiseizure medicines.
  • Haemolysis -dapsone, primaquine, nitrofurantoin, penicillins and cephalosporins.
  • Macrocytosis and low B12 -methotrexate, hydroxycarbamide, metformin, PPIs, nitrous oxide (recreational use -ask young people directly).
  • Clotting -combined pill, HRT, tamoxifen, testosterone, thalidomide or lenalidomide.
  • Raised counts -steroids (neutrophilia), testosterone (high haemoglobin).
  • Allergies -including to blood products, heparin (HIT) and iron infusions.
• Family history:
  • Bleeding disorders -haemophilia (maternal uncles, brothers -X-linked), von Willebrand disease (either parent).
  • Haemoglobinopathies -sickle cell, thalassaemia -ask about family origin (African, Caribbean, Mediterranean, Middle Eastern, South Asian, South-East Asian heritage) and carrier status.
  • G6PD deficiency, hereditary spherocytosis (family members with gallstones or splenectomy at a young age).
  • Clots in first-degree relatives; haemochromatosis; blood cancers.
• Social history:
  • Diet -meat, vegetarian or vegan (iron, B12), restrictive eating, poverty.
  • Alcohol -macrocytosis, low platelets, folate deficiency, liver disease.
  • Smoking (raised haemoglobin), recreational drugs (nitrous oxide, injecting -infections, hepatitis).
  • Occupation and exposures -benzene, radiation, lead (old paint, some traditional remedies), pesticides.
  • Travel -malaria, other infections; long-haul flights.
  • Sexual history -HIV and hepatitis risk (low platelets, lymphadenopathy, lymphoma).
  • Blood transfusion beliefs -some patients (e.g. many Jehovah's Witnesses) decline blood -ask early and record their wishes.
  • Function and support -especially for older patients facing intensive treatment.

Red Flags and Urgency

Red flag	Why it matters and what to do
Fever or feeling unwell after recent chemotherapy	Neutropenic sepsis -IV antibiotics within 1 hour
Blasts on a blood film; very high white count; pancytopenia	Possible acute leukaemia -same-day haematology review
Bruising or bleeding with petechiae and a very low platelet count	ITP, leukaemia, TTP, DIC -urgent FBC and film
Fever, confusion, kidney injury, low platelets and fragmented red cells	TTP -emergency plasma exchange
Back pain with leg weakness, numbness or bladder problems	Spinal cord compression (myeloma, lymphoma) -urgent MRI, dexamethasone
Headache, blurred vision, confusion with very high paraprotein or white count	Hyperviscosity or leucostasis -urgent haematology input
Facial swelling, distended neck veins, breathlessness	Superior vena cava obstruction (lymphoma, lung cancer)
Fever in someone without a spleen	Overwhelming post-splenectomy infection -immediate antibiotics
Chest pain, breathlessness and hypoxia in sickle cell disease	Acute chest syndrome -urgent senior review
Iron deficiency anaemia in a man or postmenopausal woman	Possible GI cancer -refer for endoscopy (NICE NG12)
Persistent unexplained lymph node enlargement, B symptoms, unexplained splenomegaly	Possible lymphoma or leukaemia -urgent FBC and suspected cancer pathway
Persistent bone pain with anaemia, high calcium or kidney injury in an older person	Possible myeloma -serum protein electrophoresis and free light chains

• NICE NG12 -offer a very urgent FBC (within 48 hours) to children and young people with unexplained petechiae or hepatosplenomegaly (and immediate referral), and consider an FBC in adults with persistent fatigue, unexplained fever, recurrent infections, generalised lymphadenopathy, unexplained bruising or bleeding, or unexplained petechiae.

Preparing for the Examination

• Introduce yourself, confirm identity, explain the examination, gain consent, offer a chaperone (especially for groin node and abdominal examination).
• Wash your hands; take extra care with infection control in neutropenic or immunosuppressed patients.
• Position -sitting up for the head, neck and nodes (examine neck nodes from behind); lying flat with one pillow for the abdomen.
• Expose appropriately -skin examination needs good light and exposure of the trunk and limbs (with dignity).
• Ask about pain before palpating (tender nodes, spleen, bones).
• Bedside clues -look for drug charts (anticoagulants, chemotherapy), transfusion in progress, IV iron, a Hickman line or PICC (cancer treatment), mouthwash and antifungals (neutropenia), oxygen.
• Order of examination -general inspection → hands → arms (bruising, pulse) → face, eyes and mouth → lymph nodes (neck, axillae, groins) → chest (sternal tenderness, heart murmurs) → abdomen (spleen, liver, ascites) → legs (DVT, ulcers, bruising) → neurology and fundi as needed → bedside tests.

General Inspection

• Overall -well or unwell, breathless at rest, distressed by pain, weight loss (cachexia), short stature (thalassaemia, chronic anaemia in childhood).
• Colour:
  • Pallor -anaemia (but skin colour is unreliable -look at conjunctivae and palmar creases).
  • Jaundice -haemolysis (lemon-yellow, mild), liver disease.
  • Plethora -red, ruddy face (polycythaemia).
  • Bronze or grey pigmentation -haemochromatosis or transfusion-related iron overload.
  • Cyanosis -methaemoglobinaemia (with normal PaO2) or lung disease; harder to see in anaemia.
• Bruising, purpura and petechiae visible at a glance -note distribution.
• Swellings -visible neck or axillary lymph nodes, facial and neck swelling (SVCO), abdominal distension (big spleen or liver, ascites).
• Skeletal changes -frontal bossing and maxillary overgrowth (thalassaemia major), kyphosis and height loss (myeloma, osteoporosis).
• Lines and devices -central venous catheter, PICC, port (infection risk, clots).
• Observations -temperature, heart rate (tachycardia in anaemia or sepsis), blood pressure (postural drop in bleeding), respiratory rate, oxygen saturation (low in acute chest syndrome; falsely normal in carbon monoxide poisoning, falsely low in methaemoglobinaemia).

Hands and Nails

• Palmar crease pallor -suggests significant anaemia (Hb under about 70–90 g/L) when creases are as pale as the surrounding skin (not reliable in darker skin).
• Koilonychia -spoon-shaped nails -iron deficiency.
• Brittle, ridged nails -iron deficiency.
• Clubbing -not usually haematological; think lung cancer, lung disease, IBD, liver disease, cyanotic heart disease, endocarditis (with anaemia).
• Splinter haemorrhages -endocarditis (with anaemia and splenomegaly), trauma.
• Nail darkening -hydroxycarbamide, B12 deficiency (hyperpigmentation of knuckles in darker skin).
• Joint signs -rheumatoid arthritis (anaemia of chronic disease, Felty's syndrome -big spleen, low neutrophils), gouty tophi (high cell turnover), haemochromatosis arthropathy (2nd and 3rd MCP joints -"iron fist").
• Dactylitis -painful swollen fingers in young children with sickle cell disease (hand-foot syndrome).
• Erythromelalgia -red, hot, painful fingers or toes (essential thrombocythaemia, polycythaemia vera).
• Raynaud's phenomenon or acrocyanosis -cold agglutinin disease, cryoglobulinaemia, paraproteins.
• Tremor, flapping tremor (liver failure), small hand muscle wasting (B12 neuropathy is mainly sensory).
• Arms -bruising (anticoagulants, steroids -senile purpura on the forearms), injection marks, AV fistula (CKD anaemia), lymphoedema.
• Pulse -tachycardia (anaemia, bleeding, sepsis); bounding (severe anaemia -high output); irregular (AF on anticoagulants; ibrutinib).

Face, Eyes and Mouth

• Conjunctivae -pallor of the lower lid's inner rim (pull down gently) -a better sign of anaemia than skin colour; conjunctival haemorrhages (low platelets, bleeding disorders); conjunctival plethora (polycythaemia).
• Sclerae -jaundice (haemolysis, liver disease) -best seen in natural light.
• Mouth:
  • Angular cheilitis (cracks at the corners) -iron, B12 or folate deficiency.
  • Glossitis -smooth, red, sore tongue -B12, folate or iron deficiency.
  • Mouth ulcers -neutropenia, chemotherapy mucositis, B12 or folate deficiency, coeliac disease, IBD.
  • Gum bleeding -low platelets, scurvy, poor dental hygiene; gum hypertrophy -monocytic AML (also phenytoin, ciclosporin, calcium channel blockers).
  • Oral purpura -"wet purpura" (blood blisters in the mouth) means a high risk of serious bleeding with low platelets.
  • Candida -immunosuppression, neutropenia, steroids.
  • Tonsils -enlarged (EBV, lymphoma), exudate.
• Face -plethora (polycythaemia), facial swelling (SVCO, nephrotic syndrome), parotid enlargement (alcohol, Sjögren's -lymphoma risk), thalassaemic facies.
• Fundi (when indicated) -retinal haemorrhages (severe anaemia, low platelets, leukaemia), Roth spots (endocarditis, leukaemia), dilated, tortuous veins and haemorrhages (hyperviscosity), papilloedema (venous sinus thrombosis), sickle retinopathy.

Skin -Bruises, Purpura and Rashes

Lesion	What it looks like	Think of
Petechiae	Pinpoint red or purple spots (under 2 mm) that don't blanch -often on legs and dependent areas	Low platelets (ITP, leukaemia, marrow failure, TTP, DIC), platelet dysfunction, vasculitis, meningococcal sepsis (with fever -emergency)
Purpura	Larger non-blanching areas (2 mm–1 cm)	Low platelets, vasculitis (palpable purpura -IgA vasculitis, small vessel vasculitis), senile purpura, steroids, scurvy
Ecchymoses (bruises)	Larger flat bruises	Anticoagulants, clotting factor deficiencies, liver disease, von Willebrand disease, trauma (consider non-accidental injury)
Palpable purpura	Raised, non-blanching spots, usually on legs and buttocks	Vasculitis (IgA vasculitis, cryoglobulinaemia, ANCA vasculitis) -not a platelet problem
Purpura fulminans	Spreading purple-black areas with skin death	DIC with sepsis (meningococcal), protein C deficiency -emergency
Perifollicular haemorrhages with corkscrew hairs	Bleeding around hair follicles	Scurvy (vitamin C deficiency -poor diet, alcohol)
Telangiectasia	Small dilated vessels on lips, tongue and fingers	Hereditary haemorrhagic telangiectasia -nosebleeds, GI bleeding, iron deficiency
Skin necrosis at injection sites	Painful dark areas	HIT (heparin injections); warfarin skin necrosis (early in treatment)

• Other skin signs -leg ulcers (sickle cell disease, hereditary spherocytosis, hydroxycarbamide), itch marks (lymphoma, polycythaemia, iron deficiency, cholestasis), herpes zoster (immunosuppression), skin infiltrates (leukaemia cutis, lymphoma), livedo reticularis (antiphospholipid syndrome), hyperpigmentation (iron overload, B12 deficiency), rashes of drug reactions or graft-versus-host disease.
• Glass test -non-blanching spots under a glass with fever in a child or adult → treat as meningococcal sepsis until proven otherwise.
• Document size, number, distribution and age of bruises (a body map helps; photographs with consent).

Lymph Nodes

• Technique -use the pads of the fingers with gentle circular movements; compare both sides; examine the neck from behind with the patient sitting and the head slightly flexed (relaxes the muscles).
• Neck sequence -submental → submandibular → preauricular → postauricular → occipital → anterior cervical chain (along sternocleidomastoid) → posterior cervical chain → supraclavicular (ask the patient to shrug or cough).
• Axillae -support the patient's arm (relaxes the muscles); feel the central, anterior (pectoral), posterior, lateral (humeral) and apical groups -use your right hand for the left axilla and vice versa.
• Groins -horizontal group (below the inguinal ligament) and vertical group (along the long saphenous vein); small mobile groin nodes are common in healthy adults.
• Other sites -epitrochlear (above the medial elbow -lymphoma, hand infections, syphilis), popliteal.
• Describe each node or group:
  • Site and size (in cm -measure).
  • Consistency -soft (normal, reactive), rubbery (lymphoma), hard (cancer spread), fluctuant (abscess, TB).
  • Tenderness -usually infection or inflammation; lymphoma is usually painless.
  • Mobility -fixed or matted nodes suggest cancer or TB.
  • Overlying skin -redness (infection), sinus (TB, actinomycosis).
  • Local or generalised (two or more separate regions).
• If you find a node, examine the area it drains -scalp, ears, mouth and throat for neck nodes; breasts and arms for axillary nodes; legs, genitals and anus for groin nodes.
• Virchow's node (left supraclavicular) -abdominal cancers (stomach); right supraclavicular -chest and oesophageal cancers.
• Normal -small (under 1 cm), soft, mobile nodes are common in the neck and groins, especially in children.

Abdomen -Spleen and Liver

• Inspect -distension, visible mass in the left upper quadrant, scars (splenectomy -left subcostal or laparoscopic port scars), striae, caput medusae (portal hypertension).
• Palpating the spleen:
  • Start in the right iliac fossa (a big spleen can reach here) and move diagonally towards the left upper quadrant, asking the patient to breathe in deeply each time -the spleen moves down on inspiration and hits your fingers.
  • If not felt, roll the patient onto their right side and palpate again (with your left hand supporting the lower left ribs).
  • A normal spleen is not palpable -a palpable spleen is usually at least twice the normal size.
• Features of a spleen (versus a left kidney):
  • Moves down and medially with breathing.
  • You can't get above it (it disappears under the ribs).
  • Has a notch on its medial edge.
  • Dull to percussion (no bowel in front).
  • Not ballotable (a kidney is ballotable and can be "got above").
• Percussion -dullness in the 9th–11th intercostal spaces in the left mid-axillary line (Traube's space) suggests enlargement when palpation is difficult.
• Measure -the distance below the left costal margin (in cm) along the line towards the right iliac fossa.
• Liver -start in the right iliac fossa and move up with breathing; percuss the upper and lower borders; describe size (cm below the costal margin), edge, surface, tenderness, pulsatility.
• Ascites -shifting dullness (portal hypertension, lymphoma, nephrotic syndrome).
• Abdominal lymph nodes or masses -para-aortic masses (lymphoma), pelvic masses.
• Splenic tenderness or rub -splenic infarction (sickle cell, endocarditis, CML, myelofibrosis).
• Don't press hard on a very large spleen in glandular fever (risk of rupture).

Bones, Joints and Nervous System

• Bones -tenderness over the spine, ribs, sternum (sternal tenderness -acute leukaemia, myeloma, marrow expansion) and long bones; kyphosis; deformity from fractures.
• Joints -haemarthrosis (warm, swollen, painful joint in haemophilia), chronic joint damage (haemophilic arthropathy -knees, elbows, ankles), avascular necrosis (hip -sickle cell disease, steroids), gout, haemochromatosis arthropathy.
• Neurological examination when symptoms suggest it:
  • B12 deficiency -reduced vibration and joint position sense, positive Romberg's test, absent ankle jerks with upgoing plantars (subacute combined degeneration), peripheral neuropathy, cognitive impairment.
  • Spinal cord compression -a sensory level, leg weakness, brisk reflexes (or reduced early), urinary retention, reduced anal tone.
  • Peripheral neuropathy -paraproteins (MGUS, Waldenström's, POEMS), amyloid (with carpal tunnel and autonomic symptoms), chemotherapy (vincristine, bortezomib, thalidomide).
  • Stroke signs -sickle cell disease, hyperviscosity, polycythaemia, antiphospholipid syndrome, TTP.
  • Cranial nerve palsies -CNS leukaemia or lymphoma, myeloma skull lesions.
• Signs of hypercalcaemia -confusion, dehydration (myeloma).

Legs

• DVT -one-sided swelling (measure calf circumference 10 cm below the tibial tuberosity -a difference of 3 cm or more is significant in the Wells score), pitting oedema, tenderness along the deep veins, warmth, dilated superficial veins; use the Wells score to guide D-dimer and ultrasound.
• Leg ulcers -around the ankles in sickle cell disease and hereditary spherocytosis; hydroxycarbamide ulcers.
• Bruising and petechiae -petechiae appear first on the legs (gravity).
• Palpable purpura on the legs and buttocks -vasculitis.
• Ankle oedema -heart failure from severe anaemia, nephrotic syndrome (clots), low albumin, drugs.
• Livedo reticularis -antiphospholipid syndrome, cryoglobulinaemia.
• Lymphoedema -after node surgery or radiotherapy, lymphoma blocking lymphatics.
• Peripheral pulses and colour -arterial clots (antiphospholipid syndrome, HIT, myeloproliferative disease); venous limb gangrene (HIT with warfarin started too early).

Completing and Presenting

• To complete the examination, say you would:
  • Check observations including temperature and postural blood pressure.
  • Do a urine dipstick (blood -haematuria or haemoglobinuria; protein -myeloma kidney, nephrotic syndrome; bilirubin and urobilinogen).
  • Perform a rectal examination (with consent and chaperone) for melaena or a mass in iron deficiency.
  • Examine the fundi, breasts, testes or full neurological system as indicated.
  • Review the drug chart, previous blood results, and the blood film.
• First tests -FBC with differential, reticulocytes, blood film, ferritin, B12, folate, U&E, LFTs, calcium, CRP, clotting screen (PT, APTT, fibrinogen), haemolysis screen (LDH, bilirubin, haptoglobin, DAT) as indicated; then targeted tests (serum protein electrophoresis and free light chains, HIV, coeliac serology, haemoglobin electrophoresis, imaging, marrow).
• Presenting -lead with the most important finding and link it to the likely diagnosis:
  • "Mr X is a 68-year-old man presenting with 3 months of night sweats and weight loss. On examination he is pale, with bilateral rubbery, non-tender cervical and axillary lymphadenopathy up to 3 cm and a spleen palpable 4 cm below the left costal margin. There are no signs of bleeding. The most likely diagnosis is lymphoma; the differential includes CLL and TB. I would like to see his FBC and blood film, and arrange a CT and a node biopsy."
• Describe positives and relevant negatives -e.g. in anaemia: no jaundice (against haemolysis), no lymphadenopathy or splenomegaly (against a blood cancer), no neuropathy (B12).

The Anaemic Patient

Cause	History clues	Examination clues
Iron deficiency	Heavy periods, GI symptoms, NSAIDs, vegetarian diet, pica, pregnancy, blood donation	Pallor, koilonychia, angular cheilitis, glossitis; abdominal or rectal mass (cancer)
B12 deficiency	Tingling, unsteadiness, memory problems, autoimmune disease, gastric surgery, vegan diet, metformin, nitrous oxide	Lemon-yellow tinge (mild jaundice), glossitis, vitiligo, reduced vibration and position sense, absent ankle jerks with upgoing plantars
Folate deficiency	Poor diet, alcohol, coeliac disease, pregnancy, methotrexate	Glossitis; signs of alcohol excess
Haemolysis	Jaundice, dark urine, gallstones, family history, new drugs, recent transfusion, cold-related symptoms	Jaundice, splenomegaly (extravascular), leg ulcers, signs of a mechanical valve (click)
Chronic disease	Inflammatory arthritis, IBD, CKD, chronic infection, cancer	Signs of the underlying disease (joints, AV fistula, weight loss)
Marrow failure or infiltration	Infections and bleeding too, bone pain, B symptoms, previous chemotherapy	Petechiae, bruising, mouth ulcers, lymphadenopathy, splenomegaly, bone tenderness
Acute bleeding	Haematemesis, melaena, trauma, anticoagulants	Tachycardia, low or postural BP, cool peripheries, melaena on rectal examination

• Signs of severity -tachycardia, flow murmur, bounding pulse, heart failure, breathlessness at rest, angina, confusion -these (not the number alone) guide urgency of treatment.

Bleeding Patterns

Feature	Platelet or von Willebrand problem	Clotting factor problem (e.g. haemophilia)
Skin	Petechiae, purpura, small bruises	Large bruises, haematomas
Mucosal bleeding	Common -nosebleeds, gums, heavy periods, GI	Less common
Deep bleeding	Rare	Joints (haemarthrosis), muscles
After cuts or procedures	Immediate bleeding	Delayed bleeding (hours later), often prolonged
Inheritance	von Willebrand -autosomal (either sex)	Haemophilia A and B -X-linked (mostly males)
Typical tests	Low platelets, or normal platelets with low vWF	Long APTT (haemophilia), long PT (warfarin, liver, vitamin K)

• Bleeding plus clotting -DIC, HIT, antiphospholipid syndrome, PNH, myeloproliferative neoplasms.
• Bleeding with a normal FBC and clotting screen -von Willebrand disease, platelet function disorders, drugs (aspirin, clopidogrel), uraemia, factor XIII deficiency, vascular causes (HHT, scurvy, Ehlers–Danlos, steroids, senile purpura).

Lymphadenopathy and Splenomegaly

• Localised lymphadenopathy -infection in the area drained (tonsillitis, dental abscess, skin infection), cancer spread, lymphoma, TB (neck -"cold" abscess), cat scratch disease.
• Generalised lymphadenopathy:
  • Infections -EBV, CMV, HIV, toxoplasmosis, TB, syphilis.
  • Blood cancers -lymphoma, CLL, acute lymphoblastic leukaemia.
  • Inflammatory -sarcoidosis, SLE, rheumatoid arthritis.
  • Drugs -phenytoin and other antiseizure drugs (pseudolymphoma, DRESS).
• Lymphadenopathy with splenomegaly -lymphoma, CLL, acute leukaemia, glandular fever, HIV, sarcoidosis, SLE.
• Splenomegaly without lymphadenopathy -CML, myelofibrosis, polycythaemia vera, portal hypertension, haemolytic anaemias, thalassaemia, malaria, leishmaniasis, endocarditis, hairy cell leukaemia.
• Size of the spleen:
  • Massive (reaching the right iliac fossa or crossing the midline) -CML, myelofibrosis, malaria, visceral leishmaniasis (Gaucher disease).
  • Moderate -the above plus lymphoma, leukaemias, portal hypertension, thalassaemia.
  • Mild (just palpable) -infections (EBV, endocarditis, hepatitis), haemolysis, autoimmune disease, early myeloproliferative disease.
• Hepatosplenomegaly -leukaemias, lymphoma, myeloproliferative disease, liver disease with portal hypertension, thalassaemia, infections, storage diseases, amyloid.
• Check for portal hypertension -stigmata of chronic liver disease, ascites, caput medusae (spleen from portal hypertension, not a blood disease).

Blood Cancers at the Bedside

Condition	Typical history	Typical signs
Acute leukaemia	Short history (weeks) of tiredness, infections, bleeding, bone pain (children)	Pallor, petechiae and bruising, mouth ulcers, fever; gum hypertrophy (monocytic AML); lymphadenopathy and hepatosplenomegaly (more in ALL)
CML	Tiredness, weight loss, sweats, abdominal fullness; often found on a routine FBC	Massive splenomegaly
CLL	Often no symptoms (raised lymphocytes on routine FBC); later tiredness, infections, B symptoms	Symmetrical painless lymphadenopathy, splenomegaly; signs of autoimmune haemolysis or ITP
Hodgkin's lymphoma	Young adult (or older adult); painless neck lump, itch, B symptoms, node pain with alcohol	Rubbery cervical or supraclavicular nodes, mediastinal mass
Non-Hodgkin's lymphoma	Older adult; enlarging nodes (slow in low grade, rapid in high grade), B symptoms	Lymphadenopathy (often several regions), splenomegaly, extranodal disease (gut, skin, brain)
Myeloma	Over 60; back pain, tiredness, thirst, infections, kidney problems	Pallor, bone tenderness, kyphosis, dehydration; no lymphadenopathy or big spleen usually
Polycythaemia vera	Itch after bathing, headache, burning hands and feet, clots, gout	Plethora, conjunctival injection, splenomegaly (in some)
Myelofibrosis	Older adult; tiredness, weight loss, sweats, abdominal discomfort	Pallor, massive splenomegaly, hepatomegaly
Myelodysplasia	Older adult; slowly worsening tiredness, infections, bruising; previous chemotherapy	Pallor, bruising; usually no lymphadenopathy or splenomegaly

Special Situations

• Sickle cell crisis:
  • Assess pain quickly and give analgesia within 30 minutes; ask what usually works and what the patient's usual Hb is (check care plan).
  • Examine for acute chest syndrome (chest signs, hypoxia), stroke (focal neurology), splenic sequestration in children (enlarging spleen, falling Hb, shock), priapism, signs of infection, jaundice, and hip pain (avascular necrosis).
• The neutropenic patient -fever may be the only sign; examine mouth, skin, line sites, chest, perianal area (inspect only -no rectal examination), and sinuses; take cultures and start antibiotics without waiting.
• Suspected transfusion reaction -stop the transfusion; check the patient's identity against the unit; record temperature, pulse, BP, respiratory rate and oxygen saturation; look for urticaria, wheeze, raised JVP (TACO), loin pain, dark urine.
• Patient on anticoagulants with a fall or head injury -full neurological examination; low threshold for CT head (NICE head injury guidance); check the drug and time of last dose.
• Pregnancy -anaemia is common (dilutional and iron deficiency); ask about haemoglobinopathy screening, previous clots, bleeding disorders and anti-D; examine for VTE and pre-eclampsia (HELLP -low platelets).
• Children -bruising patterns (safeguarding), pallor, growth, lymphadenopathy (often reactive), hepatosplenomegaly, bone pain or limp (leukaemia); unexplained petechiae or hepatosplenomegaly needs immediate referral (NICE NG12).
• Older people -anaemia is often multifactorial (iron, B12, CKD, chronic disease, myelodysplasia); medicines review; falls and anticoagulation; capacity and wishes about investigation and treatment.

Signs at a Glance

Sign	Think of
Conjunctival and palmar crease pallor	Significant anaemia
Koilonychia, angular cheilitis	Iron deficiency
Glossitis	B12, folate or iron deficiency
Mild jaundice with pallor	Haemolysis; B12 deficiency (ineffective red cell production)
Plethora	Polycythaemia
Bronze pigmentation	Iron overload (haemochromatosis, transfusions)
Petechiae, wet purpura in the mouth	Low platelets -high bleeding risk
Palpable purpura on legs	Vasculitis
Haemarthrosis	Haemophilia, anticoagulant excess
Gum hypertrophy	Monocytic AML (or phenytoin, ciclosporin, CCBs)
Mouth ulcers and fever	Neutropenia
Rubbery painless lymphadenopathy	Lymphoma
Hard, fixed nodes	Metastatic cancer
Left supraclavicular node	Abdominal (gastric) cancer
Massive splenomegaly	CML, myelofibrosis, malaria, leishmaniasis
Splenomegaly with lymphadenopathy	Lymphoma, CLL, leukaemia, EBV, HIV
Sternal or bone tenderness	Acute leukaemia, myeloma
Absent ankle jerks with upgoing plantars	B12 deficiency (subacute combined degeneration)
Leg ulcers in a young person	Sickle cell disease, hereditary spherocytosis
Frontal bossing, maxillary overgrowth	Thalassaemia major
Telangiectasia on lips with iron deficiency	Hereditary haemorrhagic telangiectasia
Livedo reticularis with clots	Antiphospholipid syndrome
Facial swelling, distended neck veins	SVC obstruction (lymphoma, lung cancer)
Splenectomy scar	Hyposplenism -vaccines and antibiotic prophylaxis

Spot the Diagnosis

Clue	Diagnosis
Woman with heavy periods, craving ice, spoon-shaped nails	Iron deficiency anaemia
Pale, lemon-tinged, tingling feet, unsteady with eyes closed, vitiligo	Pernicious anaemia (B12 deficiency)
Jaundice, splenomegaly, gallstones at 18, father had splenectomy	Hereditary spherocytosis
Dark urine and jaundice after fava beans or an antimalarial	G6PD deficiency
Fingers turn blue in the cold, anaemia after a Mycoplasma chest infection	Cold agglutinin haemolysis
Child with petechiae and bruising 2 weeks after a viral illness, otherwise well	ITP
Fever, confusion, petechiae, kidney injury and jaundice	TTP
Boy with a swollen painful knee after a minor fall; maternal uncle similar	Haemophilia (haemarthrosis)
Lifelong nosebleeds, heavy periods, bleeding after dental extractions; mother similar	Von Willebrand disease
Young woman with DVT, previous stroke and two miscarriages	Antiphospholipid syndrome
Itch after hot showers, plethora, splenomegaly, headache	Polycythaemia vera
Burning red toes relieved by aspirin, platelets 1,100	Essential thrombocythaemia (erythromelalgia)
Young man with painless neck node, itch and night sweats	Hodgkin's lymphoma
70-year-old with symmetrical painless nodes and lymphocytes of 45	CLL
Weight loss, sweats and a spleen reaching the right iliac fossa; WCC 180	CML
Teardrop cells, massive spleen, older adult	Myelofibrosis
Back pain, thirst, constipation, anaemia and AKI in a 72-year-old	Myeloma
Short history of bruising, mouth ulcers, fever and gum swelling	Acute myeloid leukaemia (monocytic)
Child with a limp, pallor, bruising and hepatosplenomegaly	Acute lymphoblastic leukaemia
Headache, blurred vision and nosebleeds with a very high IgM paraprotein	Hyperviscosity (Waldenström's)
Facial swelling and distended neck veins in a young man with a mediastinal mass	SVC obstruction (lymphoma)
Nosebleeds, red spots on the lips and tongue, iron deficiency	Hereditary haemorrhagic telangiectasia
Gum bleeding, corkscrew hairs and bruising in a man living on toast and tea	Scurvy
Bronze skin, diabetes, arthritis of the 2nd and 3rd knuckles	Haemochromatosis
Fever with a splenectomy scar	Overwhelming post-splenectomy infection

Exam-style Scenarios

1. A 34-year-old woman presents with tiredness and breathlessness on climbing stairs. She has heavy periods lasting 8 days with clots, and has been vegetarian for 5 years. She has spoon-shaped nails and pale conjunctivae.
Answer: Likely iron deficiency anaemia from menstrual loss and low dietary iron.

• History -quantify periods (flooding, clots, changing protection hourly), coeliac symptoms, GI bleeding, pica; family history of bleeding disorders (heavy periods since menarche -von Willebrand disease).
• Tests -FBC, ferritin, coeliac serology; consider von Willebrand screening if bleeding history suggests it.
• Treatment -oral iron once daily or alternate days; manage heavy periods (e.g. levonorgestrel IUS, tranexamic acid); dietary advice.

2. A 7-year-old boy has had bruises on his legs and nosebleeds for 3 days. He had a cold 2 weeks ago. He is well, with scattered petechiae, no lymphadenopathy and no splenomegaly. Platelets are 12 × 10⁹/L; Hb and white cells are normal.
Answer: Probable immune thrombocytopenia (ITP).

• Key features -isolated low platelets in a well child after a viral illness, with no lymphadenopathy, splenomegaly, bone pain or abnormal other counts (which would suggest leukaemia).
• Same-day paediatric haematology review; blood film; look for wet purpura and bleeding severity.
• Most resolve without treatment; avoid contact sports, NSAIDs and IM injections; treat if significant bleeding; safeguarding is part of the assessment of any bruised child.

3. A 71-year-old man has 3 months of back pain, thirst and constipation. Hb 89 g/L, adjusted calcium 3.05 mmol/L, creatinine 210. He is tender over the lumbar spine.
Answer: Suspected multiple myeloma (CRAB features).

• Ask about infections, weight loss, neurological symptoms (cord compression), and bubbly urine (light chains).
• Examine -neurology of the legs, bladder; signs of dehydration; bone tenderness elsewhere.
• Urgent tests -serum protein electrophoresis, serum free light chains, urine Bence Jones protein, blood film (rouleaux), imaging (whole-body MRI or low-dose CT); IV fluids and treatment of hypercalcaemia; urgent haematology referral.

4. A 26-year-old man with sickle cell disease presents with chest pain, fever and a respiratory rate of 30. Oxygen saturation is 89% on air; there are crackles at the right base.
Answer: Acute chest syndrome.

• Oxygen, analgesia (within 30 minutes), incentive spirometry, IV fluids with care, antibiotics including atypical cover.
• Chest X-ray, FBC and reticulocytes, group and screen (extended phenotype), blood gas.
• Urgent haematology and critical care review -transfusion or exchange transfusion; monitor for deterioration.

5. A 58-year-old woman is referred with a lymphocyte count of 9.8 × 10⁹/L found on a routine blood test. She feels well. She has small, painless, mobile nodes in both sides of the neck and both axillae. No splenomegaly.
Answer: Likely early-stage chronic lymphocytic leukaemia.

• History -B symptoms, infections, bleeding, autoimmune symptoms (haemolysis, ITP).
• Tests -blood film (smudge cells), flow cytometry (immunophenotyping), Hb and platelets (staging), DAT, immunoglobulins.
• Most early CLL is monitored ("watch and wait"); vaccinations (non-live), prompt treatment of infections; irradiated blood if treated with certain drugs.

Key Points

• Ask about the five ways blood disorders present: anaemia, bleeding, infection, clots and lumps.
• B symptoms -fevers, drenching night sweats, over 10% weight loss in 6 months.
• Platelet problems cause petechiae and mucosal bleeding; factor problems cause joint and muscle bleeds and delayed bleeding.
• Previous surgery or dental extractions without bleeding are reassuring.
• Haemophilia is X-linked (ask about male relatives on the mother's side); von Willebrand affects both sexes.
• Clots in unusual sites suggest myeloproliferative disease, PNH, antiphospholipid syndrome or cancer.
• Iron deficiency anaemia in men and postmenopausal women needs GI investigation.
• Look at conjunctivae and palmar creases for pallor; sclerae for jaundice.
• Koilonychia and angular cheilitis -iron deficiency; glossitis -B12, folate or iron.
• Wet purpura (blood blisters in the mouth) means high bleeding risk.
• Examine neck nodes from behind; describe site, size, consistency, tenderness and mobility; examine the drainage area.
• Palpate the spleen from the right iliac fossa towards the left upper quadrant; roll the patient onto the right side if not felt.
• Spleen: moves with breathing, notch, can't get above it, dull to percussion.
• Massive splenomegaly: CML, myelofibrosis, malaria, leishmaniasis.
• Myeloma usually has no lymphadenopathy or big spleen; think of it with back pain, anaemia, high calcium and AKI.
• Fever after recent chemotherapy is neutropenic sepsis until proven otherwise.
• Unexplained petechiae or hepatosplenomegaly in a child needs immediate referral.
• Always take a full drug history -many blood problems are drug-induced.

Guidelines and Further Reading

• NICE NG12: Suspected cancer -recognition and referral (haematological cancers)
• British Society of Gastroenterology: Guidelines for the management of iron deficiency anaemia in adults
• British Society for Haematology (BSH) guidelines -ITP, haemolytic anaemia, B12 and folate, bleeding disorders
• ISTH Bleeding Assessment Tool
• NICE NG158: Venous thromboembolic diseases
• NICE CG143: Sickle cell disease -managing an acute painful episode in hospital
• NICE CG151: Neutropenic sepsis
• NICE NG24: Blood transfusion
• Macleod's Clinical Examination -haematological system
• BNF -for current doses