Adult Internal Medicine: Haematology

Presentations

• Chemotherapy side effects, such as mucositis, nausea, pain, and vomiting

Conditions

• Bony lytic lesions
• Complications from blood transfusion
• Complications of immunosuppression
• Disorders of coagulation or thrombosis, such as:
  • disseminated intravascular coagulation
  • thrombophilia
  • use of anticoagulants and antiplatelet agents
  • use of antifibrinolytic agents
  • venous thromboembolic events, such as deep vein thrombosis and pulmonary embolism and complications
• Graft versus host disease
• Haematological emergencies, such as:
  • febrile neutropenia
  • hypercalcaemia of malignancy
  • spinal cord compression
  • tumour lysis syndrome
• Haematological malignancies:
  • Hodgkin lymphoma
  • leukaemia, acute and chronic
  • myelodysplasia
  • myeloproliferative disease
  • non-Hodgkin lymphoma
  • plasma cell dyscrasias and multiple myeloma
• Increase in cell counts, such as:
  • leucocytosis
  • polycythaemia
  • thrombocytosis
• Reduction in cell counts, such as:
  • anaemia
  • neutropenia
  • thrombocytopenia

For each presentation and condition, Basic Trainees will know how to:

Synthesise

• recognise the clinical presentation
• identify relevant epidemiology, pathophysiology, and clinical science
• take a relevant clinical history
• conduct an appropriate examination
• establish a differential diagnosis
• plan and arrange appropriate investigations
• consider the impact of illness and disease on patients¹ and their quality of life

Manage

• provide evidence-based management
  For less common or more complex presentations and conditions the trainee must also seek expert opinions
• prescribe therapies tailored to patients’ needs and conditions
• recognise potential complications of disease and its management, and initiate preventative strategies
• involve multidisciplinary teams

Consider other factors

• identify individual and social factors and the impact of these on diagnosis and management

Conditions

• Amyloidosis
• Aplastic anaemia or bone marrow failure
• Bleeding disorders, such as haemophilia and von Willebrand disease (vWD)
• Complications of therapeutic interventions, such as catheter-related infections and thromboses, and anticoagulant-related skin necrosis
• Cutaneous manifestations of haematological disease, such as cutaneous lymphoma
• Haemolytic disorders

For each presentation and condition, Basic Trainees will know how to:

Synthesise

• recognise the clinical presentation
• identify relevant epidemiology, pathophysiology, and clinical science
• take a relevant clinical history
• conduct an appropriate examination
• establish a differential diagnosis
• plan and arrange appropriate investigations
• consider the impact of illness and disease on patients¹ and their quality of life

Manage

• provide evidence-based management
  For less common or more complex presentations and conditions the trainee must also seek expert opinions
• prescribe therapies tailored to patients’ needs and conditions
• recognise potential complications of disease and its management, and initiate preventative strategies
• involve multidisciplinary teams

Consider other factors

• identify individual and social factors and the impact of these on diagnosis and management

• Haemoglobin structure and function
• Haemoglobinopathies, such as thalassaemia and sickle cell disease
• Iron, B12, and folate metabolism
• Principles of transfusion and bone marrow transplantation
• Process of coagulation
• Structure and function of blood-forming tissues, reticulo-endothelial system, and blood components and process of haematopoiesis

Investigations

• Basic coagulation tests, such as activated partial thromboplastin time (aPTT), D-dimer, fibrinogen levels, international normalised ratio (INR), and prothrombin time (PT)
• Blood group tests
• Bone marrow aspirate and trephine
• CT scans in the diagnosis of lymphadenopathy or hepatosplenomegaly
• Cytogenetic and molecular studies:
  • BCR-ABL t(9;22)
  • Janus kinase 2 (JAK2) V617F
  • PML-RARA / t(15;17)
  • AML, CLL, lymphoma and myeloma - molecular risk criteria
• Full blood count and blood film
• Iron studies
• Lymph node biopsy
• Peripheral blood and bone marrow immunophenotyping (know indications for flow cytometry, and the basic immunophenotypes of haematological cancers)
• PET scans (know indications only)
• Serum B12 and folate levels
• Serum or urine electrophoresis, immunofixation, and free light chain assays
• Skeletal survey and other imaging modalities, particularly in relation to myeloma diagnosis (know indications only)
• Tests available for patients on direct oral anticoagulants (DOACs):
  • anti-Xa assays
  • dilute thrombin time
• Tests of haemolysis:
  • bilirubin
  • direct antiglobulin test
  • haptoglobin
  • lactate dehydrogenase (LDH)
  • reticulocyte count
• Thrombophilia screens

• Appropriate use of blood transfusion products
• Impact of new cancer diagnoses on patients and the formulation of relevant and holistic management plans
• Issues relating to haematological disease in adolescents, such as:
  • comorbid disease
  • emotional, intellectual, physical, psychological, and social factors
  • legal and ethical principles
  • principles of sexual and reproductive health, particularly in the context of chemotherapy
  • risk behaviours
  • transition of care from paediatric health facilities
• Multidisciplinary team approach to management of haematology patients and in assisting patients with hospital discharge, outpatient care, assisted living arrangements, and end-of-life care
• Palliative care options for patients with terminal haematological diseases, and consultation with palliative care and psychosocial services
• Patients’ cultural and religious backgrounds in the context of treating haematological conditions
• Social factors that influence management of haematological diseases, including cultural, geographic, religious, and socio-economic factors
• Usage of alternative or complementary therapies