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MALAYSIA
Intake ME 2/16
Semester 2
INTRODUCTION
During the five weeks of this module you will cover the basic science of diseases
involving haemopoietic system. The lifelong production of blood cells occurs in
haemopoietic tissue.
The reticulo-endothelial system comprises the spleen, liver, lymph nodes and
lymphatic ducts and lymphoid tissues. The bone marrow produces the cells which
are found in these tissues & organs, and the blood which circulates throughout the
body. In certain situations, haemopoiesis may occur outside the bone marrow
(extra-medullary haemopoiesis).
In the clinical skills sessions you will learn to interview patients presenting with
haematology problems and to perform physical examination pertaining to the
haemopoieic system.
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Why haematology module is important?
Learning outcomes:
Communication skills
1. To elicit a comprehensive family history from a patient.
2. To summarize a patient history in an organized and concise manner
3. To communicate effectively with patients while carrying out an invasive
procedure
4. To obtain consent from a patient to perform a procedure/physical
examination
Practical skills
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Session outline
Learning Outcomes
Please view the video on the examination of the Haemopoietic System on your own
from the IMU E-Learning Portal before your clinical teaching session in the Skills
Centre.
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References:
You are strongly encouraged to read the following chapters from textbooks in the
library for a better idea on what is a complete physical examination to the
haematological system.
http://www.oxfordmedicaleducation.com/clinical-examinations/lump-bump-examination
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The examination may be summarized as in the table below:
Taken from Examination Medicine. 6th Edition. Nicholas J Talley and Simon O’ Connor,
Section 15, page 317
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You should be able to describe the lymph node swelling based on the
following criteria
• SITE
• SHAPE AND SIZE
• CONSISTENCY
o Rubbery – suggestive of lymphoma
o Hard – suggestive of carcinoma
o Matted – sometimes found in tuberculosis
• MARGIN
• ATTACHMENTS / FIXATION
o To skin or deep structures
o If fixed to underlying structures, more likely to be infiltrated by
carcinoma
• TENDERNESS – implies infection or acute inflammation
• OVERLYING SKIN
o Inflammation of overlying skin suggest infection
o Tethering to the overlying skin suggest carcinoma
Inspection:
• Site – describe in relation to fixed anatomical landmarks
• Size and shape
• Colour of skin – e.g. red, pigmented
• Abnormaility of skin – e.g. peau d’orange in breast carcinoma
• Abnormal vessels
• Visible pulsations - aneurysm (abdominal mass)
Palpation:
• Tenderness – ask for this first
• Temperature
• Size – measurement with a tape measure or ruler in 2 dimensions
Eg:(5x5cm )
• Shape- Oval, spherical or round
• Consistency – soft, firm, hard, rubbery, lobulated
• Surface – smooth, rough, irregular , flat or raised
• Margins – well defined or ill defined
• Mobility
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• Fixation - is it tethering of the skin or is it attached to the underlying
structures
• Fluctuation – indicates presence of fluid ( Dermoid cyst)
• Pulsations or thrills
http://www.oxfordmedicaleducation.com/clinical-examinations/lump-bump-examination/
Gentle reminder!
1. Please palpate the lump gently eventhough you only examine the model.
2. Not all of the ways of assessing a lump mentioned above are needed in
every lymph node examination.Therefore, cater your examination to the
individual.
Learning Outcomes:
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Coagulation disorders:
• Factor deficiency – haemophilia A and B
• Combined factor and platelet deficiency – von Willebrand’s disease
• Platelet dysfunction – Bernard-Soulier syndrome (rare)
Reference:
You are strongly advised to read the following chapters to help you understand the
important points within each component of history taking for within the
haematological system.
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WEEK 3: VENEPUNCTURE
Learning outcomes:
https://youtu.be/RKuUPO6NNcU
Reference
Procedure
• Check the patient’s identification ( at least 2 id’s) to ensure that the correct
patient is having the procedure
• Know the samples you need to collect and identify the right evacuated tubes
with the amount of blood samples needed for each
• Organize your equipment and place them in a tray to take with you
• Inspect the patient’s surface anatomy for suitable veins and observe for any of
the contraindications mentioned above
• Apply the tourniquet 5-10cm proximal for better visualization of the veins
(NEVER leave tourniquet on for more than 2 minutes)
• Disinfect selected site starting from the centre and work in circular movement
outwards. Allow time to dry. Do NOT touch the cleaned site.
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• Assemble the needle and syringe
• Insert needle, puncturing the skin with the bevel facing UPWARDS with a 15-30
degree angle (depending on how superficial the vein is).
• Once collected sufficient amount of blood, have your gauze pad ready.
Remove the tourniquet then carefully remove the needle from the skin and
cover the punctured site with the gauze. Apply firm pressure for about 3-4
minutes. ( You can instruct your patient to apply firm pressure with gauze too)
• Recheck the venepunture site before you dress the site with bandage or
adhesive strips.
• Remove your gloves, dispose them into clinical waste bin and wash your hands.
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WEEK 4: PUTTING ALL TOGETHER
Learning Outcomes:
You will be given two case scenarios whereby you will practise your history taking
skills as well as connecting the information received in the history to the physical
findings in the examination. From there, you will learn to form a relevant and concise
summary of the case. You will also learn to generate a list of differential diagnoses of
the cases seen. You will be expected to present the cases in the large group for
discussion purposes. Please revise some common haematological diseases
(Haemophilia/ Von Wilibrand disease/ Nutritional deficiency anaemia/Thalassemia/
ITP before attending this class.
Scenario 1
You are currently posted to the outpatient clinic. A 16-year-old teenager complains
of having gum bleeding for 2 days. Interview him regarding his problem and arrive at
your most likely diagnosis.
Scenario 2
You are in the medical ward now. A 50-year-old lady has been admitted for feeling
tired for the past 2 months.She has a history of chronic renal disease for 10
years.Gather relevant information about her problem and summarise your findings.
Scenario 3
You are posted to the haematology clinic. A 55-year-old retired school teacher
complains of having a swelling on the right side of his neck. Interview him and
perform relevant physical examination on this patient.
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Glossary of important Malay words
Fatigue Letih
Weakness Lemah
Dizziness Pening
Numbness Kebas
Bruising Lebam
Lumps Ketulan
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