Hematologic Examination

Introduction to Hematologic Examination

• General Context and Challenges:

  • Hematologic examination is considered one of the most challenging and complex physical examinations because the hematologic system is scattered throughout the body, unlike localized systems such as respiratory or cardiovascular.

  • The examination requires the practitioner to identify and integrate key points located in disparate anatomical regions.

  • Main Focus Areas: In a hematologic context, the two most critical components are the palpation of the lymph nodes and the evaluation of the spleen.

• Rashes in the Face-to-Face (F2F) Exam:

  • Rash cases are not a common feature of the face-to-face Australian Medical Council (AMC) exam because it is considered "boring" to show a photo outside and then have the student enter the room; it fails to replicate the clinical environment effectively.

  • One historical case involved Immune Thrombocytopenic Purpura ($ITP$), but this has not been seen in recent recalls.

  • Students will be provided with terminology for primary and secondary morphology of rashes (e.g., how to explain a rash), but should not focus excessively on rashes for F2F exams unless specifically directed.

Initial Steps: Preparation, Introduction, and Consent

• WIPE and Introduction:

  • The examiner must perform hand hygiene, introduce themselves (e.g., "My name is Amir"), and explain the process to the patient.

  • Explanation to the Patient: "I will be looking at different parts of your body, including your arms, your face, and your stomach. I will be feeling for glands in your armpits, your neck, and your groin, and feeling your stomach for organs. I will also be gently tapping on your stomach."

• Positioning and Exposure:

  • The examination involves significant patient movement.

  • Initial Position: The patient should start in a sitting position to facilitate the examination of the cervical, axillary, and epitrochlear lymph nodes.

  • Later Position: The patient will need to lie down for the abdominal portion of the exam (feeling for the liver and spleen).

  • Exposure: Ensure adequate exposure of the arms and the abdomen (stomach).

General Appearance and Specific Signs

• Observation Key Points:

  • Cachexia: Defined as severe wasting. This is a critical sign for hematologic malignancies such as leukemia or lymphoma.

  • Scratch Marks: Highly emphasized in AMC exams. The presence of scratch marks is often a positive finding suggestive of lymphoma.

  • Pallor: Indicates anemia, which is a common manifestation of various hematologic disorders.

  • Jaundice: Results from the breakdown of cells (hemolysis) leading to increased bilirubin.

  • Rashes: Specifically, look for non-blanching rashes categorized under purpura.

• Purpura Classification:

  • Petechiae: Small, pinpoint purpuric lesions.

  • Ecchymosis: Large, bruise-like purpuric lesions.

  • Differentials for purpura include $ITP$, myeloproliferative disorders, infections, vasculitis, marrow problems, and leukemia.

Hand and Arm Examination

• Nails:

  • Clubbing: A standard part of general examination that must be assessed.

  • Koilonychia: Brittle, spoon-shaped nails that are a specific feature of severe iron deficiency anemia.

• Vascular Signs:

  • Raynaud's phenomenon: Discoloration of fingers sometimes associated with hematologic issues.

  • Digital Infarctions: Painful bruises on the fingers resulting from vascular compromise in certain hematologic conditions.

• Epitrochlear Lymph Nodes:

  • Importance: According to Talley and O'Connor, these must always be palpated.

  • Anatomical Location: They are located in the medial aspect of the arm, proximal and anterior to the medial epicondyle, situated between the biceps and triceps muscles.

  • Technique: Use the "same palm, same elbow" rule. For the left arm, place your left palm under the elbow and use your thumb to feel the area. This must be done bilaterally.

  • Note on Accuracy: Palpating the wrong spot (e.g., the medial groove meant for cubital tunnel syndrome/ulnar nerve assessment) is considered an inaccurate examination and may lead to failure in a F2F exam.

Characteristics of Lymphadenopathy

If a lymph node is palpated, the following features must be assessed and reported:

• Size: Measurement of the node.

• Consistency: Is it normal, rubbery, or "stony hard"? Stony hard nodes are suggestive of malignancy.

• Tenderness: Painful nodes suggest lymphadenitis (infection/inflammation), while non-painful nodes are more concerning for malignancy.

• Mobility / Fixation: Benign nodes move freely; malignant nodes are often fixed to underlying tissues due to adhesions.

• Overlying Skin: Look for redness or signs of inflammation.

Axillary Lymph Node Examination

• Technique:

  • Must be performed bilaterally.

  • Use the opposite hand for palpation (e.g., use your right hand to palpate the patient's left axilla).

  • Relaxation: To feel nodes effectively, muscles must be relaxed. Abduct the patient's arm and rest their forearm on your forearm.

• The ECLIPSE Mnemonic for Axillary Groups:

  1. Central: Located deep in the center of the axilla.

  2. Lateral (Humeral): Located along the upper part of the humerus.

  3. Pectoral (Anterior): Located just under the pectoral muscle.

  4. Infraclavicular (Apical): Very deep nodes located just below the clavicle.

  5. Subscapular (Posterior): Located under the scapular muscles at the back.

Face, Mouth, and Throat Examination

• Face:

  • Conjunctival Pallor: Ask the patient to look up while pulling the eyelid down.

  • Scleral Jaundice: Ask the patient to look down to check for yellowing of the sclera.

• Mouth:

  • Gums: Look for hypertrophy (overgrowth) and bleeding, common in leukemia.

  • Tongue: Look for Atrophic Glossitis (a smooth, shiny, inflamed tongue) and Angular Cheilitis (redness/fissuring at the corners of the mouth).

• Throat:

  • Tonsillar Enlargement: Tonsils are part of the hematologic and immune system.

  • Waldeyer’s Ring: A lymphatic ring at the back of the throat including the adenoids and lingual tonsils. Note any swelling or enlargement in this ring.

Cervical Lymph Node Chain

• Methodology: Standing behind the patient is the preferred method for F2F exams. Palpate eight chains using both hands:

  1. Submental: Under the chin.

  2. Submandibular: Under the jawline.

  3. Jugular (Anterior Cervical): Anterior to the sternocleidomastoid ($SCM$) muscle.

  4. Posterior Triangle (Posterior Cervical): Behind the $SCM$ muscle.

  5. Pre-auricular: In front of the ear.

  6. Post-auricular: Behind the ear.

  7. Occipital: At the base of the skull.

  8. Supraclavicular: Above the clavicle (ask the patient to shrug their shoulders to facilitate access).

• Bony Tenderness: This is a critical key point. While checking supraclavicular nodes, palpate the clavicle and the sternum for tenderness, which can indicate bone marrow expansion or malignancy.

Abdominal Examination: Spleen and Liver

• Inspection: Look for swelling, distension, or visible masses. Observe if the abdomen moves symmetrically with respiration.

• Spleen Palpation:

  • Bimanual Technique: This is mandatory for accuracy. Place the left hand behind the patient’s left posterolateral ribs to provide support. Use the right hand to palpate starting from the right lower quadrant ($RLQ$), specifically below the umbilicus, and move diagonally toward the left costal margin.

  • Rotation: If not felt, ask the patient to roll onto their right side to allow the spleen to displace downward and forward. Perform one final deep palpation under the costal margin.

• Spleen Percussion (The Castell Method):

  • This is the preferred, specific method for F2F exams.

  • Location: The lowest intercostal space in the anterior axillary line.

  • Procedure: Percuss in this space while the patient takes a deep breath in and again while they breathe out.

  • Interpretation: Dullness on inspiration is suggestive of splenomegaly ($diaphragm$ pushes the enlarged spleen into the percussion area). Resonant results on both indicate a normal spleen.

  • Note on Traube’s Space: This is an alternative method (borders: $6^{th}$ rib, left costal margin, anterior axillary line), but it is considered more vague than Castell's.

• Liver Palpation: Move from the $RLQ$ toward the right upper quadrant ($RUQ$) during inspiration. In a hematologic exam, you may skip liver percussion to save time, focusing on the quality of the liver edge.

Other Regional Lymph Nodes and Lower Limbs

• Inguinal Lymph Nodes:

  • Two chains: horizontal (along the inguinal ligament) and vertical (along the femoral vessels).

  • F2F Protocol: Students must mention they want to check these, but role players/examiners will usually grant a skip because of the proximity to private parts. Missing the mention counts as a missed key point.

• Para-aortic Nodes: Not routinely examined as they are too deep to palpate through abdominal fat and bowels.

• Popliteal Lymph Nodes: Palpated occasionally, but rarely required in F2F unless specifically noted.

• Lower Limb Assessment: Look for ulcers, scratch marks, or peripheral neuropathy. These are often skipped in F2F due to time constraints, provided the spleen and lymph nodes are thoroughly examined.

Fundoscopy and Conclusion

• Fundoscopy: Relevant for myeloproliferative disorders or leukemia to check for engorged retinal vessels or papilledema. However, it is rarely performed in the F2F hematologic exam.

• Final Rule for Success: To pass a hematologic station, focus entirely on a complete lymph node examination and a nice, complete spleen examination. Everything else is secondary.