Presenting symptoms (Table 8.1)

Patients with anaemia may present with weakness, tiredness, dyspnoea, fatigue or postural dizziness. Anaemia due to iron deficiency is often the result of gastrointestinal blood loss, or sometimes recurrent heavy menstrual blood loss, and so these symptoms should be sought. Disorders of platelet function or blood clotting may present with easy-bruising or bleeding problems. Recurrent infection may be the first symptom of a disorder of the immune system, including leukaemia or HIV infection. The patient may have noticed lymph node enlargement, which can occur with lymphoma or leukaemia. Not all lumps are lymph nodes; consider the differential diagnosis (Table 8.2). Ask about fever, its duration and pattern. Lymphomas can be a cause of chronic fever, and viral infections such as cytomegalovirus and infectious mononucleosis are associated with haematological abnormalities and fever.

TABLE 8.1 Haematological history

TABLE 8.2 Differential diagnosis of lymphadenopathy

Treatment

Anaemia may have been treated with iron supplements or B₁₂ injections. Anti-inflammatory drugs or anticoagulants may be the cause of bleeding. Treatment for leukaemia or lymphoma may have involved chemotherapy, radiotherapy, or both; or bone marrow transplant. There may have been blood transfusions in the past.

Past history

A history of gastric surgery or malabsorption may give a clue regarding the underlying cause of an anaemia. Anaemia in patients with systemic disease such as rheumatoid arthritis or uraemia can be multifactorial. Previous blood transfusions may have been required to treat the anaemia. On the other hand, patients with polycythaemia may have had many venesections (page 236).

Social history

A patient’s racial origin is relevant. Thalassaemia is common in people of Mediterranean or southern Asian origin. Rarely, very strict vegetarian diets can result in vitamin B₁₂ deficiency. Find out the patient’s occupation and whether there has been work exposure to toxins such as benzene (risk of leukaemia). Has the patient had previous chemotherapy for a malignancy (drug-related development of leukaemia)? Does the patient drink alcohol?

Family history

There may be a history of thalassaemia or sickle cell anaemia in the family. Haemophilia is a sex-linked recessive disease while von Willebrand’s disease^a is autosomal dominant with incomplete penetrance (Table 8.3).

TABLE 8.3 Causes of ecchymoses

Examination anatomy

An important part of the examination involves assessment of all the palpable groups of lymph nodes. As each group is examined its usual drainage area must be kept in mind (Figure 8.1). It follows that whenever an abnormality is discovered anywhere that might be due to infection or malignancy its draining lymph nodes must be examined.

Figure 8.1 Usual drainage areas of lymph nodes

Adapted from Epstein O et al, Clinical Examination, 4th edn, Edinburgh: Mosby, 2008.

General appearance

Position the patient as for the gastrointestinal examination—lying on the bed with one pillow. Look for signs of wasting and for pallor (which may be an indication of anaemia—Good signs guide 3.1, page 26). ^1–3 Note the patient’s racial origin (e.g. thalassaemia). If there is any bruising, look at its distribution and extent. Jaundice may be present and can indicate haemolytic anaemia. Scratch marks (following pruritus, which sometimes occurs with lymphoma and myeloproliferative disease) should be noted.

The hands

The detailed examination begins in the usual way with assessment of the hands. Look at the nails for koilonychia—these are dry, brittle, ridged, spoon-shaped nails, which are rarely seen today. They can be due to severe iron deficiency anaemia, although the mechanism is unknown. Occasionally koilonychia may be due to fungal infection. They may also be seen in Raynaud’s phenomenon. Digital infarction (Figure 8.2) may be a sign of abnormal globulins (e.g. cryoglobulinaemia). Pallor of the nail beds may occur in anaemia but is an unreliable sign. Pallor of the palmar creases suggests that the haemoglobin level is less than 70 g/L, but this is also a rather unreliable sign.¹

Figure 8.2 Digital infarction

Note any changes of rheumatoid or gouty arthritis, or connective tissue disease (Chapter 9). Rheumatoid arthritis, when associated with splenomegaly and neutropenia, is called Felty’s syndrome^b: the mechanism of the neutropenia is unknown, but it can result in severe infection. Felty’s syndrome can also be associated with thrombocytopenia (Figure 8.3), haemolytic anaemia, skin pigmentation and leg ulceration. Gouty tophi and arthropathy may be present in the hands. Gout may be a manifestation of a myeloproliferative disease. Connective tissue diseases can cause anaemia because of the associated chronic inflammation.

Figure 8.3 Thrombocytopenic purpura

Now take the pulse. A tachycardia may be present. Anaemic patients have an increased cardiac output and compensating tachycardia because of the reduced oxygen-carrying capacity of their blood.

Look for purpura (Figure 8.3), which is really any sort of bruising, due to haemorrhage into the skin. The lesions can vary in size from pinheads called petechiae (from Latin petechia ‘a spot’) (Table 8.4) to large bruises called ecchymoses (Table 8.3).

TABLE 8.4 Causes of petechiae

^* Eduard Henoch (1820–1910), professor of paediatrics, Berlin, described this in 1865, and Johannes Schönlein (1793–1864), Berlin physician, described it in 1868.

If the petechiae are raised (palpable purpura), this suggests an underlying systemic vasculitis, where the lesions are painful, or bacteraemia.

The forearms

If thrombocytopenia or capillary fragility is suspected, the Hess test^c can be performed.^d

Epitrochlear nodes

These must always be palpated. The best method is to flex the patient’s elbow to 90 degrees, abduct the upper arm a little and then place the palm of the right hand under the patient’s right elbow (Figure 8.4). The examiner’s thumb can then be placed over the appropriate area, which is proximal and slightly anterior to the medial epicondyle. This is repeated with the left hand for the other side. An enlarged epitrochlear node is usually pathological. It occurs with local infection, non-Hodgkin’s lymphoma^e or rarely syphilis. Note the features and different causes as listed in tables 8.5 and 8.6. Certain symptoms and signs suggest that lymphadenopathy may be the result of a significant disease (Good signs guide 8.1).

Figure 8.4 Feeling for the epitrochlear lymph node

TABLE 8.5 Characteristics of lymph nodes

TABLE 8.6 Causes of localised lymphadenopathy

GOOD SIGNS GUIDE 8.1 Factors suggesting lymphadenopathy is associated with significant disease

Axillary nodes

To palpate these, the examiner raises the patient’s arm and, using the left hand for the right side, pushes his or her fingers as high as possible into the axilla. The patient’s arm is then brought down to rest on the examiner’s forearm. The opposite is done for the other side (Figure 8.5).

Figure 8.5 Feeling for the axillary lymph nodes

There are five main groups of axillary nodes: (i) central; (ii) lateral (above and lateral); (iii) pectoral (medial); (iv) infraclavicular; and (v) subscapular (most inferior) (Figure 8.6). An effort should be made to feel for nodes in each of these areas of the axilla.

Figure 8.6 The main groups of axillary lymph nodes

A = central; B = lateral; C = pectoral; D = infraclavicular; E = subscapular.

The face

The eyes should be examined for the presence of scleral jaundice, haemorrhage or injection (due to increased prominence of scleral blood vessels, as in polycythaemia). Conjunctival pallor suggests anaemia and is more reliable than examination of the nail beds or palmar creases.³ In northern Europeans the combination of prematurely grey hair and blue eyes may indicate a predisposition to the autoimmune disease pernicious anaemia, where there is a vitamin B₁₂ deficiency due to lack of intrinsic factor secretion by an atrophic gastric mucosa.

The mouth should be examined for hypertrophy of the gums, which may occur with infiltration by leukaemic cells, especially in acute monocytic leukaemia, or with swelling in scurvy. Gum bleeding must also be looked for, and ulceration, infection and haemorrhage of the buccal and pharyngeal mucosa noted. Atrophic glossitis occurs with megaloblastic anaemia or iron deficiency anaemia. Multiple telangiectasiae may appear around the mouth or in the mouth in patients with hereditary haemorrhagic telangiectasia. Look to see if the tonsils are enlarged. Waldeyer’s ring^f is a circle of lymphatic tissue in the posterior part of the oropharynx and nasopharynx, and includes the tonsils and adenoids. Sometimes non-Hodgkin’s lymphoma will involve Waldeyer’s tonsillar ring, but Hodgkin’s disease rarely does.

Cervical and supraclavicular nodes

Sit the patient up and examine the cervical nodes from behind. There are eight groups. Attempt to identify each of the groups of nodes with your fingers (Figure 8.7). First palpate the submental node, which lies directly under the chin, and then the submandibular nodes, which are below the angle of the jaw. Next palpate the jugular chain, which lies anterior to the sternomastoid muscle, and then the posterior triangle nodes, which are posterior to the sternomastoid muscle. Palpate the occipital region for occipital nodes and then move to the postauricular node behind the ear and the preauricular node in front of the ear. Finally from the front, with the patient’s shoulders slightly shrugged, feel in the supraclavicular fossa and at the base of the sternocleidomastoid muscle for the supraclavicular nodes. Causes of lymphadenopathy, localised and generalised, are given in Table 8.7. Note that small cervical nodes are often palpable in normal young people.^4,5

Figure 8.7 Cervical and supraclavicular lymph nodes

1 = submental; 2 = submandibular; 3 = jugular chain; 4 = supraclavicular; 5 = posterior triangle; 6 = postauricular; 7 = preauricular; 8 = occipital.

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