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4 Part I: Clinical Evaluation of the Patient Chapter 1: Initial Approach to the Patient: History and Physical Examination 5

TABLE 1–1. Findings That May Lead to a Hematology TABLE 1–3. Eastern Cooperative Oncology Group
Consultation Performance Status 5
Decreased hemoglobin concentration (anemia) Grade Activity
Increased hemoglobin concentration (polycythemia) 0 Fully active, able to carry on all predisease perfor-
Elevated serum ferritin level mance without restriction
Leukopenia or neutropenia 1 Restricted in physically strenuous activity but ambula-
Immature granulocytes or nucleated red cells in the blood tory and able to carry out work of a light or sedentary
Pancytopenia nature, e.g., light housework, office work
Granulocytosis: neutrophilia, eosinophilia, basophilia, or 2 Ambulatory and capable of all self-care but unable to
mastocytosis carry out any work activities; up and about more than
Monocytosis 50% of waking hours
Lymphocytosis 3 Capable of only limited self-care, confined to bed or
Lymphadenopathy chair more than 50% of waking hours
Splenomegaly 4 Completely disabled; cannot carry on any self-care;
Hypergammaglobulinemia: monoclonal or polyclonal totally confined to bed or chair
Purpura 5 Dead
Thrombocytopenia Oken MM, Creech RH, Tormey DC, et al: Toxicity and response criteria
Thrombocytosis of the Eastern Cooperative Oncology Group. Am J Clin Oncol.
Exaggerated bleeding: spontaneous or trauma related
Prolonged partial thromboplastin or prothrombin coagulation times anemia or hemolytic anemia, fever may be present. Chills may accom-
Venous thromboembolism pany severe hemolytic processes and the bacteremia that may compli-
Thrombophilia cate the immunocompromised or neutropenic patient. Night sweats
Obstetrical adverse events (e.g., recurrent fetal loss, stillbirth, and suggest the presence of low-grade fever and may occur in patients with
HELLP syndrome) lymphoma or leukemia.
Fatigue, malaise, and lassitude are such common accompaniments
HELLP, hemolytic anemia, elevated liver enzymes, and low platelet of both physical and emotional disorders that their evaluation is complex
count. and often difficult. In patients with serious disease, these symptoms may
be readily explained by fever, muscle wasting, or other associated findings.
TABLE 1–2. Criteria of Performance Status (Karnofsky Patients with moderate or severe anemia frequently complain of fatigue,
Scale) 4 malaise, or lassitude and these symptoms may accompany the hematologic
Able to carry on normal activity; no special care is needed. malignancies. Fatigue or lassitude may occur also with iron deficiency
even in the absence of sufficient anemia to account for the symptom.
100% Normal; no complaints, no evidence of disease In slowly developing chronic anemias, the patient may not recognize
90% Able to carry on normal activity; minor signs or reduced exercise tolerance, or other loss of physical capabilities except in
symptoms of disease retrospect, after a remission or a cure has been induced by appropriate
80% Normal activity with effort; some signs or therapy. Anemia may be responsible for more symptoms than has been
symptoms of disease traditionally recognized, as suggested by the remarkable improvement in
Unable to work; able to live at home, care for most personal quality of life of most uremic patients treated with erythropoietin.
needs; a varying amount of assistance is needed. Weakness may accompany anemia or the wasting of malignant
70% Cares for self; unable to carry on normal activity processes, in which cases it is manifest as a general loss of strength or
or to do active work reduced capacity for exercise. The weakness may be localized as a result
60% Requires occasional assistance but is able to care of neurologic complications of hematologic disease. In vitamin B defi-
12
for most personal needs ciency (e.g., pernicious anemia), there may be weakness of the lower
50% Requires considerable assistance and frequent extremities, accompanied by numbness, tingling, and unsteadiness of
medical care gait. Peripheral neuropathy also occurs with monoclonal immunoglob-
Unable to care for self; requires equivalent of institutional or ulinemias. Weakness of one or more extremities in patients with leuke-
hospital care; disease may be progressing rapidly. mia, myeloma, or lymphoma may signify central or peripheral nervous
40% Disabled; requires special care and assistance system invasion or compression as a result of vertebral collapse, a para-
neoplastic syndrome (e.g., encephalitis), or brain or meningeal involve-
30% Severely disabled; hospitalization is indicated ment. Myopathy secondary to malignancy occurs with the hematologic
though death not imminent malignancies and is usually manifest as weakness of proximal muscle
20% Very sick; hospitalization necessary; active groups. Foot drop or wrist drop may occur in lead poisoning, amyloi-
supportive treatment necessary dosis, systemic autoimmune diseases, or as a complication of vincristine
10% Moribund; fatal processes progressing rapidly therapy. Paralysis may occur in acute intermittent porphyria.
0% Dead
SPECIFIC SYMPTOMS OR SIGNS
Adapted with permission from Mor V, Laliberte L, Morris JN, Wiemann
M: The Karnofsky performance status scale: An examination of Nervous System
its reliability and validity in a research setting Cancer 1984 May 1; Headache may be the result of a number of causes related to hematologic
53(9):2002–2007. diseases. Anemia or polycythemia may cause mild to severe headache.

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