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Hematology Propaedeutics - Complete Study Guide for Practical Oral Exam

3rd Year Clinical Introduction | Focus: History-Taking & Physical Examination

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PART 1 - INTRODUCTION TO THE HEMATOLOGY CONSULTATION

1. Disorders of red blood cells (RBCs) - anemias, polycythemia
2. Disorders of white blood cells (WBCs) - leukemia, lymphoma, neutropenia
3. Disorders of hemostasis - bleeding disorders, thrombophilia, platelet disorders

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PART 2 - HISTORY-TAKING IN HEMATOLOGY

2.1 Opening and Chief Complaint

• Always introduce yourself, confirm the patient's identity, and ask open-ended: "What brings you in today?"
• Common chief complaints in hematology:
  • Fatigue, weakness, shortness of breath (anemia)
  • Abnormal bleeding or bruising (coagulopathy / thrombocytopenia)
  • Swollen glands / lumps in the neck, axilla, groin (lymphadenopathy)
  • Bone pain (multiple myeloma, leukemia)
  • Fever, night sweats, weight loss ("B symptoms" - lymphoma)
  • Recurrent infections (leukemia, immunodeficiency)

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2.2 History of Presenting Complaint (HPC) - Use the OLDCARTS Framework

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2.3 Symptoms of Anemia - Ask Specifically About:

• Fatigue and weakness - the most common but least specific symptom
• Dyspnea on exertion - patient gets breathless with activities they previously tolerated
• Palpitations / tachycardia - heart compensates by beating faster
• Dizziness, lightheadedness, syncope - reduced cerebral oxygenation
• Exertional chest pain - especially if the patient has underlying coronary artery disease or the anemia is severe
• Edema - decreased renal blood flow triggers neurohormonal activation (similar to heart failure mechanism), but unlike heart failure, cardiac output is actually HIGH in anemia
• Headache and difficulty concentrating - common, often overlooked
• Cold intolerance - peripheral vasoconstriction

Clinical pearl: Symptoms of hypovolemia (thirst, postural hypotension, rapid weak pulse) only occur in acute anemia from large blood loss - in chronic anemia, plasma volume expands to compensate.

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2.4 Symptoms of Bleeding Disorders - Ask About:

• Epistaxis (nosebleeds) - spontaneous or prolonged after minor trauma
• Gum bleeding
• Easy bruising - bruises appearing with minimal or no trauma
• Petechiae - patient may notice tiny red dots on legs
• Heavy menstrual periods (menorrhagia)
• Prolonged bleeding from cuts

• Hemarthrosis - bleeding into joints (classic for hemophilia)
• Muscle hematomas
• Prolonged bleeding after surgery, tooth extractions, injections
• Intracranial hemorrhage (rare, serious)

Key distinction: Platelet disorders cause immediate superficial bleeding (skin, mucous membranes). Coagulation disorders cause delayed deep bleeding (joints, muscles).

• Respiratory: hemoptysis, epistaxis
• Gastrointestinal: hematemesis (vomiting blood), melena (black tarry stools), hematochezia (fresh rectal blood)
• Genitourinary: hematuria, menorrhagia, abnormal pregnancies
• Skin: petechiae, ecchymoses

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2.5 Symptoms Suggesting Lymphoproliferative Disease (Lymphoma / Leukemia)

1. Fever - unexplained fever > 38°C
2. Night sweats - drenching, requiring change of clothes or sheets
3. Weight loss - unexplained loss of >10% body weight in 6 months

• Painless swollen lymph nodes - in the neck, armpits, or groin
• Pruritus (itching) - without obvious skin cause, classic in Hodgkin lymphoma
• Alcohol-induced pain at lymph node sites - pathognomonic for Hodgkin lymphoma (rare but high-yield)
• Recurrent or severe infections - suggests neutropenia or immune dysfunction (leukemia)
• Bone pain - leukemia infiltrating marrow, or multiple myeloma
• Abdominal fullness / early satiety - from splenomegaly

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2.6 Past Medical History (PMH)

• Chronic kidney disease - causes anemia of chronic disease (reduced erythropoietin)
• Liver disease - affects clotting factor production; causes thrombocytopenia from hypersplenism
• Inflammatory / autoimmune diseases (rheumatoid arthritis, lupus, IBD) - anemia of chronic inflammation; also autoimmune hemolytic anemia
• Hypothyroidism - causes normocytic anemia, macrocytosis
• Cancer - bone marrow infiltration causing pancytopenia
• Previous surgeries - especially gastrectomy (impairs B12 absorption) or bowel resection
• Previous blood transfusions - alloimmunization, transfusion reactions
• Previous episodes of DVT/PE - suggests thrombophilia

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2.7 Drug and Medication History

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2.8 Family History

• Sickle cell disease / sickle cell trait - autosomal recessive, common in Sub-Saharan African, Mediterranean, and Middle Eastern populations
• Thalassemia - autosomal recessive, common in Mediterranean, Middle Eastern, South Asian populations
• Hemophilia A & B - X-linked recessive (affects males, carrier females)
• Von Willebrand disease - autosomal dominant (most common inherited bleeding disorder)
• Hereditary spherocytosis - autosomal dominant hemolytic anemia
• G6PD deficiency - X-linked, triggers hemolytic episodes
• Familial polycythemia, hereditary thrombophilia (Factor V Leiden, prothrombin mutation)

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2.9 Social History

• Diet and nutrition: Vegetarian/vegan diet risks iron and B12 deficiency. Strict veganism: B12 deficiency (megaloblastic anemia). Poor nutrition: folate deficiency.
• Alcohol use: Causes macrocytosis, thrombocytopenia, and folate deficiency
• Occupation: Toxin/chemical exposure (benzene, radiation) - risk for aplastic anemia, leukemia
• Travel history: Malaria (hemolytic anemia), visceral leishmaniasis, schistosomiasis - all cause splenomegaly/anemia
• Ethnic/racial background: Guides suspicion for hereditary disorders (sickle cell, thalassemia, G6PD deficiency)
• Smoking: Associated with polycythemia

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2.10 Menstrual History (Female Patients)

• Regularity and frequency of periods
• Duration and heaviness of flow - menorrhagia is a major cause of iron-deficiency anemia in premenopausal women AND can be the presenting symptom of a bleeding disorder (e.g., von Willebrand disease)
• Number of pads/tampons used (>80 mL blood loss per cycle = menorrhagia)
• Pregnancy history

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2.11 Review of Systems (ROS) - Do Not Miss These

• Skin: Jaundice, pallor, petechiae, ecchymoses, pruritus, leg ulcers
• Eyes: Yellowing of sclera (jaundice from hemolysis)
• Mouth: Mouth sores, sore tongue
• Lymph nodes: Any lumps?
• Cardiorespiratory: Dyspnea, palpitations, chest pain
• GI: Abdominal pain, fullness, bowel changes, rectal bleeding
• Neurological: Numbness, tingling, weakness, balance problems (B12 deficiency)
• Musculoskeletal: Bone pain, joint swelling/bleeding

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PART 3 - PHYSICAL EXAMINATION IN HEMATOLOGY

3.1 General Inspection - First Impressions

• Pallor (pale skin suggesting anemia)
• Jaundice (yellow skin and sclerae suggesting hemolysis or liver disease)
• Cyanosis (blue discoloration - hypoxia, methemoglobinemia)
• Cachexia / weight loss (malignancy)
• General distress or fatigue

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3.2 Vital Signs

• Pulse rate: Tachycardia compensates for anemia (HR >100 bpm at rest suggests significant anemia)
• Blood pressure: Postural hypotension in acute blood loss
• Respiratory rate: Elevated with severe anemia
• Temperature: Fever can indicate infection (neutropenia), lymphoma, or hemolysis

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3.3 Skin Examination

How to distinguish petechiae from a rash: Press with a glass (diascopy). A rash blanches (blood pushed out). Petechiae do NOT blanch (extravasated blood does not move).

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3.4 Eye Examination

• Conjunctival pallor: The most reliable clinical sign of anemia
  • Examine the lower eyelid: pull it down and look at the inferior palpebral conjunctiva
  • Conjunctival rim pallor (LR+ 16.7): The normally bright red anterior rim of the inferior palpebral conjunctiva is the same pale pink color as the deeper posterior aspect - very specific for anemia
  • Palmar crease pallor (LR+ 7.9): Also highly useful - look at the lines of the palm; normally pink even when the hand is extended; if the palmar creases are white/pale, anemia is very likely
  • Facial pallor and nail bed pallor are less reliable (LR+ < 5)
• Scleral icterus (jaundice): Yellow coloration of the whites of the eyes - hemolysis or liver disease; best seen in natural daylight (fluorescent light masks yellow)
• Fundoscopy: Retinal hemorrhages, Roth spots (endocarditis, leukemia, severe anemia)

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3.5 Mouth and Oropharynx

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3.6 Lymph Node Examination

1. Submental and submandibular (under the chin)
2. Cervical - anterior and posterior chains
3. Occipital
4. Preauricular and postauricular
5. Supraclavicular (highly significant - Virchow's node on the left suggests GI malignancy)
6. Axillary
7. Epitrochlear (above the elbow)
8. Inguinal
9. Popliteal (behind the knee - often overlooked)

• Size (in cm - >1 cm in adults is generally pathological)
• Consistency: Soft (reactive/infectious), firm/rubbery (lymphoma), hard/rock-like (metastatic carcinoma)
• Tenderness: Tender = usually reactive/infectious. Painless = suspicious for lymphoma or malignancy
• Mobility: Mobile = benign. Fixed to underlying tissue = malignant
• Warmth and erythema: Suggests acute infection
• Location: Localized vs. generalized

• Localized tender nodes + infection signs = reactive lymphadenopathy
• Generalized lymphadenopathy = systemic illness (viral: EBV, CMV; bacterial; hematologic malignancy)
• Supraclavicular node is ALWAYS concerning - must be investigated

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3.7 Abdominal Examination - Spleen and Liver

Splenomegaly (Enlarged Spleen)

• Patient lies supine, comfortably relaxed
• Start palpation from the right iliac fossa (the right lower quadrant) - a massively enlarged spleen can extend far across the abdomen and you will miss it if you start in the left upper quadrant
• Move your hand toward the left upper quadrant on each inspiration - the spleen moves down with the diaphragm during inspiration
• Ask the patient to take deep breaths - the spleen is best felt on inspiration
• The spleen notch distinguishes it from the kidney

• Traube's space = the area over the left lower chest (8th-11th ribs in the anterior axillary line)
• Normally resonant (air in stomach and bowel)
• Dull percussion in Traube's space suggests splenomegaly

• Left upper quadrant fullness/pain, early satiety
• Cytopenia (hypersplenism trapping blood cells)
• In children: malaria, infectious mononucleosis (EBV), sickle cell

• Hematologic: Lymphoma, leukemia (especially CML - massive splenomegaly), hemolytic anemias, myeloproliferative disorders, thalassemia
• Infectious: EBV (glandular fever), malaria, visceral leishmaniasis, septicemia
• Portal hypertension: Liver cirrhosis, portal vein thrombosis
• Inflammatory: SLE, rheumatoid arthritis (Felty's syndrome)

Hepatomegaly

• Enlarged liver from infiltrative disease (lymphoma, leukemia), hepatitis, cirrhosis
• Examine from the right iliac fossa upward
• Measure the number of finger-breadths below the costal margin

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3.8 Cardiovascular Examination

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3.9 Neurological Examination

Subacute combined degeneration due to B12 deficiency is a classic exam favorite. Dorsal (posterior) and lateral columns of the spinal cord are demyelinated. Patient has impaired proprioception AND weakness.

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3.10 Musculoskeletal and Bone Examination

• Bone tenderness on palpation: Sternal tenderness (press firmly on the sternum) - suggests bone marrow infiltration in leukemia or multiple myeloma
• Joint swelling and deformity: Hemarthrosis in hemophilia - chronic joint disease from repeated bleeds (hemophilic arthropathy)
• Vertebral tenderness: Multiple myeloma can cause vertebral collapse

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3.11 Examination for Signs of Specific Disorders

Signs of Iron-Deficiency Anemia:

• Pallor (conjunctival, palmar crease)
• Koilonychia (spoon-shaped nails)
• Angular cheilitis
• Atrophic glossitis (smooth tongue)
• Dysphagia (Plummer-Vinson/Patterson-Kelly syndrome - rare)

Signs of B12/Folate Deficiency (Megaloblastic Anemia):

• Pallor with lemon-yellow tinge (mild jaundice from ineffective erythropoiesis)
• Smooth tongue (glossitis)
• Neurological signs (B12 only - folate does NOT cause neurological disease): loss of vibration, proprioception, ataxia

Signs of Hemolysis:

• Jaundice (scleral icterus)
• Pallor
• Splenomegaly (extramedullary hematopoiesis and RBC destruction)
• Dark urine (hemoglobinuria in intravascular hemolysis)

Signs of Leukemia:

• Pallor (anemia from marrow infiltration)
• Petechiae and ecchymoses (thrombocytopenia)
• Fever, recurrent infections (neutropenia)
• Lymphadenopathy
• Splenomegaly, hepatomegaly
• Gum hypertrophy (especially AML)
• Sternal tenderness
• Bone pain

Signs of Lymphoma:

• Painless lymphadenopathy (rubbery, non-tender nodes)
• B symptoms: fever, night sweats, weight loss
• Pruritus (especially Hodgkin)
• Splenomegaly, hepatomegaly
• Superior vena cava (SVC) syndrome (facial swelling, arm swelling) if mediastinal involvement

Signs of Multiple Myeloma:

• Bone pain, bone tenderness (vertebral collapse)
• Pallor (anemia)
• Recurrent infections (immunoparesis)
• Features of hypercalcemia: nausea, confusion, constipation, polyuria
• Peripheral neuropathy (paraprotein-related)

Signs of Bleeding Disorders:

• Petechiae, purpura, ecchymoses
• Hemarthrosis (joint swelling - hemophilia)
• Mucous membrane bleeding (gums, epistaxis)

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PART 4 - PUTTING IT TOGETHER: CLINICAL APPROACH

4.1 The Three-Question Framework

1. Is there evidence of anemia? (pallor, tachycardia, fatigue, flow murmur)
2. Is there evidence of a bleeding/clotting disorder? (petechiae, ecchymoses, hemarthrosis, thrombosis)
3. Is there evidence of lymphoproliferative/myeloproliferative disease? (lymphadenopathy, splenomegaly, B symptoms, bone pain)

4.2 The Clinical Significance of Pallor

• Conjunctival rim pallor: LR+ 16.7 - most useful sign
• Palmar crease pallor: LR+ 7.9 - second most useful
• Facial pallor / nail bed pallor: LR+ < 5 - less reliable
• No single physical sign rules out anemia
• Overall sensitivity and specificity of physical exam for anemia is ~70%

Practical tip for the oral exam: Always order a CBC if a patient has symptoms suggesting anemia, even if physical exam signs are absent. Do NOT rely solely on the physical exam.

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PART 5 - SUMMARY TABLE: SYMPTOMS AND THEIR HEMATOLOGIC INTERPRETATION

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PART 6 - PRACTICAL TIPS FOR THE ORAL EXAM

1. Structure your answer always in the same order: Chief complaint → HPC (OLDCARTS) → PMH → Medications → Family history → Social history → Review of systems → Physical examination
2. Always link the symptom to the mechanism: Don't just say "fatigue." Say "fatigue due to reduced oxygen delivery from anemia."
3. When examining, verbalize what you are doing and why: "I am starting palpation from the right iliac fossa because in massive splenomegaly the spleen can extend to the left lower quadrant."
4. Petechiae vs. rash: Use the glass test - petechiae don't blanch.
5. B symptoms are asked in every lymphoma case - if you forget to ask, the examiner will notice.
6. Sternal tenderness is a quick bedside test - always perform it if you suspect leukemia or myeloma.
7. Don't forget the neurological exam in any anemia case - B12 deficiency has combined blood and neuro findings.
8. Family history - always ask about hereditary blood disorders, especially if the patient is young.
9. Conjunctival pallor is your best tool for detecting anemia - never skip it.
10. The spleen moves on inspiration and has a notch - both features distinguish it from kidney or other left upper quadrant masses.

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• Blood loss (acute vs. chronic)
• Hemolytic - inherited: Hereditary spherocytosis, G6PD deficiency, PK deficiency, Sickle cell disease, Beta & Alpha thalassemia
• Hemolytic - acquired: PNH, AIHA (warm & cold), MAHA
• Underproduction: Megaloblastic (B12/pernicious vs. folate), Iron deficiency, Anemia of chronic inflammation, Aplastic anemia, Renal anemia, Myelophthisic anemia
• Plus: Polycythemia vera (excess RBCs)

• Vessel wall: HSP, Hereditary hemorrhagic telangiectasia, Scurvy
• Platelet disorders: ITP (chronic & acute), HIT, TTP, HUS, Glanzmann, Bernard-Soulier, drug-induced
• Coagulation: Hemophilia A & B, vWD, Vitamin K deficiency, DIC

• AML, ALL, CML, CLL
• Hodgkin & Non-Hodgkin lymphoma (with specific translocations)
• Multiple myeloma

• PV, ET, Primary myelofibrosis, MDS

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1. CBC - every parameter with reference ranges, formulas, and how to interpret each number
2. MCV classification - the master framework for all anemias (microcytic / normocytic / macrocytic) with full differential lists
3. RDW - how to use it to distinguish iron deficiency from thalassemia (key exam distinction)
4. WBC differential - what each cell elevation or reduction means
5. Platelet count - thresholds and clinical significance at each level
6. Reticulocyte count and RPI - why the raw percentage misleads you, how to correct it, and how to use it to divide all anemias into hyperproductive vs. hypoproductive
7. Peripheral blood smear - every abnormal cell morphology with its specific diagnosis (the most image-rich, exam-heavy topic)
8. Iron studies - all four parameters (serum iron, TIBC, TSAT, ferritin) explained mechanistically and as a pattern recognition table
9. Hemolysis panel - LDH, haptoglobin, bilirubin, Coombs test, and how to distinguish intravascular from extravascular hemolysis
10. B12 and folate testing - including the MMA test and how to distinguish the two
11. Coagulation tests - PT/INR, aPTT, TT, fibrinogen, D-dimer with full diagnostic pattern table for every bleeding disorder
12. Bone marrow examination - indications, sites, what each finding means, and the molecular/flow cytometry tests ordered from it

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• Microcytic anemias (6 disorders): IDA, anemia of chronic inflammation, β and α thalassemia, sideroblastic anemia, copper deficiency
• Normocytic anemias - high RPI group (hemolytic): acute blood loss, warm AIHA, cold AIHA, hemolytic disease of newborn, all 6 causes of MAHA (TTP, HUS, DIC, HELLP, malignant hypertension, prosthetic valve), HS, G6PD, PNH
• Normocytic anemias - low RPI group (underproductive): aplastic anemia, renal anemia, hypothyroidism, myelophthisic anemia, pure red cell aplasia
• Macrocytic anemias (6 disorders): B12 deficiency, folate deficiency, drug-induced megaloblastosis, alcohol, liver disease, MDS
• High Hb/erythrocytosis: polycythemia vera, all causes of secondary polycythemia
• WBC disorders: reactive neutrophilia, leukemoid reaction, EBV mononucleosis, CML, CLL, AML, ALL, viral neutropenia, drug-induced agranulocytosis, autoimmune neutropenia, Felty syndrome
• Platelet disorders: ITP, acute ITP, HIT, TTP, HUS, DIC, hypersplenism, reactive thrombocytosis, essential thrombocythemia