Haematological Examination
A 10-section haematological examination looking for anaemia, bleeding, lymphadenopathy and hepatosplenomegaly, including comments on findings.
Haematology · Self-paced
10 sections · 49 actionable steps
Before you begin
Equipment
Pen torch
Tongue depressor
Stethoscope
Tendon hammer
128 Hz tuning fork
The aim
Look for anaemia, bleeding, infection and infiltration of the nodes, liver and spleen.
The marrow makes red cells, white cells and platelets. Each step looks for signs of too few, too many or abnormal cells.
How to use this guide
Read it through: Learn the sequence and the reason behind each step before you practise.
Practise in pairs: One examines, one reads the steps aloud and ticks each circle as it is completed.
Present aloud: Finish every attempt with a concise summary, as you would for an examiner.
The sequence
Talk
Introduce, consent, position
Look
General, hands, face, mouth
Nodes
Every node group, bones
Abdomen
Spleen, liver, groin
Close
Legs and summary
Step 1. Introduction
Hand hygiene
Hand wash/rub
Introduce yourself
Introduce yourself to the patient
Explain the purpose
Explain the purpose of the examination
Obtain consent
Obtain consent
Ask about pain
Ask about any pain, particularly in the bones or abdomen, before you start
Position and exposure
Sit the patient at 45° with the upper body exposed; expose the abdomen and legs later
Set up first
Check the bedside for transfusions, central lines and the temperature chart: fever may mean neutropenic sepsis.
Step 2. General Inspection
Pallor
Pale skin and mucous membranes suggest anaemia
Jaundice
Yellow skin or sclerae suggest haemolysis or liver disease
Weight loss
Cachexia suggests malignancy or chronic disease
Skin
Bruising, petechiae, purpura, rashes or signs of infection
Plethora
A ruddy complexion suggests polycythaemia
Surroundings
Transfusion bags, central lines, oxygen and the temperature chart
Name the bleeding
Petechiae (under 2 mm) and purpura (2–10 mm) do not blanch and suggest a platelet problem. Large ecchymoses suggest a clotting problem.
Palpable purpura
Raised purpura that you can feel suggests vasculitis rather than low platelets.
Step 3. The Hands
Nails
Koilonychia (spoon-shaped nails) in iron deficiency; clubbing
Palmar crease pallor
Pale palmar creases with the fingers extended suggest severe anaemia
Joints
Rheumatoid arthritis (Felty’s syndrome) or haemophilic arthropathy
Skin
Petechiae, bruising or vasculitic lesions
Iron deficiency
Koilonychia, angular stomatitis and glossitis together point to long-standing iron deficiency.
Step 4. The Arms and Pulse
Radial pulse
Tachycardia in anaemia, bleeding or infection
Bruising and petechiae
Inspect the forearms, including around the cuff site
Venepuncture sites
Cannula and venepuncture sites for bruising or bleeding
Epitrochlear nodes
Support the elbow at 90° and palpate above the medial epicondyle
Blood pressure (comment only)
Comment only — do not performA postural drop suggests blood loss
Step 5. The Face and Mouth
Conjunctival pallor
Gently pull down the lower eyelid and look at the inner rim
Scleral icterus
Look for yellowing of the sclerae
Gums
Hypertrophy, bleeding or infection
Tongue and lips
Glossitis and angular stomatitis
Oral cavity
Ulcers, candida, petechiae on the palate and enlarged tonsils
Fundoscopy (comment only)
Comment only — do not performRetinal haemorrhages or signs of hyperviscosity
Mouth clues
Gum hypertrophy: monocytic leukaemia or drugs such as phenytoin, ciclosporin and nifedipine.
Glossitis: iron, B12 or folate deficiency.
Step 6. The Lymph Nodes
Cervical and supraclavicular nodes
Stand behind the patient. Submental, submandibular, pre- and post-auricular, occipital, cervical chains and supraclavicular nodes
Axillary nodes
Support the patient’s arm. Palpate the central, anterior, posterior, lateral and apical groups
Describe any nodes
Site, size, consistency, tenderness, fixity and number
Describe a node
Rubbery: lymphoma. Hard and fixed: metastatic cancer. Tender: infection. Nodes over 1 cm are usually significant.
Virchow’s node
An enlarged left supraclavicular node can indicate gastric or other abdominal malignancy.
Step 7. Bone Tenderness
Sternum
Press gently over the sternum
Clavicles and shoulders
Press gently along each clavicle
Spine
Gently percuss the spinous processes with the patient leaning forward
Why the bones?
Bone tenderness suggests marrow infiltration: myeloma, leukaemia or metastases.
Step 8. The Abdomen
Reposition
Lie the patient flat with one pillow and expose the abdomen
Inspect
Distension, or fullness in the left upper quadrant
Palpate the spleen
Start in the right iliac fossa and move towards the left costal margin with each breath in
Roll onto the right side
If the spleen is not felt, roll the patient towards you and palpate again
Percuss the spleen
Dullness over the left lower ribs (Traube’s space) suggests splenomegaly
Palpate the liver
Start in the right iliac fossa and move up with each breath in
Inguinal nodes
Palpate the horizontal and vertical groups on each side
Start low
A massive spleen can reach the right iliac fossa. Start there or you may miss it.
Spleen or kidney?
The spleen has a notch, you cannot get above it, it moves towards the right iliac fossa on breathing in and is dull to percussion.
Examiner note
Offer to examine the testes and perform a digital rectal examination.
Step 9. The Lower Limbs
Skin
Bruising, purpura and leg ulcers
Joints
Swelling from a haemarthrosis
Calves
Swelling, warmth or tenderness suggesting deep vein thrombosis
Vibration and proprioception
Test at the great toe; loss suggests B12 deficiency
Reflexes and plantars
Absent ankle jerks with upgoing plantars suggest subacute combined degeneration
B12 deficiency
Subacute combined degeneration: loss of vibration and position sense, absent ankle jerks and upgoing plantars.
Step 10. Conclusion
Thank the patient
Thank the patient and help them to cover up
Hand hygiene
Hand wash/rub
Summarise
Anaemia, bleeding, lymphadenopathy, hepatosplenomegaly and any complications
Suggest further investigations
Full blood count and blood film, then targeted tests
Finish strongly
Summarise the abnormalities in groups, give your most likely diagnosis, then offer a blood film and targeted tests.
Run it from memory
Cover the steps and recite the sequence.
- Step 1. Introduction
- Step 2. General Inspection
- Step 3. The Hands
- Step 4. The Arms and Pulse
- Step 5. The Face and Mouth
- Step 6. The Lymph Nodes
- Step 7. Bone Tenderness
- Step 8. The Abdomen
- Step 9. The Lower Limbs
- Step 10. Conclusion
What your findings mean
Anaemia by red cell size
Mean cell volume guides the differential
| Type | MCV | Common causes | Examination clues |
|---|---|---|---|
| Microcytic | Under 80 fL | Iron deficiency, thalassaemia, anaemia of chronic disease | Koilonychia, angular stomatitis, glossitis |
| Normocytic | 80–100 fL | Acute blood loss, chronic disease, kidney disease, haemolysis, marrow failure | Jaundice and splenomegaly in haemolysis |
| Macrocytic | Over 100 fL | B12 or folate deficiency, alcohol, liver disease, hypothyroidism, myelodysplasia, drugs | Glossitis, neuropathy, signs of liver disease |
Causes of splenomegaly
| Degree | Causes |
|---|---|
| Massive | Chronic myeloid leukaemia, myelofibrosis, malaria, visceral leishmaniasis |
| Moderate | Lymphoma, leukaemia, portal hypertension, haemolytic anaemia |
| Mild | Infection such as EBV, endocarditis or viral hepatitis |
Patterns of lymphadenopathy
| Pattern | Possible cause |
|---|---|
| Localised and tender | Local infection |
| Generalised and rubbery | Lymphoma or chronic lymphocytic leukaemia |
| Hard and fixed | Metastatic carcinoma |
| With splenomegaly | Lymphoma, CLL, EBV or HIV |
Bleeding patterns
| Feature | Platelets or vessels | Clotting factors |
|---|---|---|
| Skin | Petechiae, purpura | Large bruises |
| Mucosa | Gum bleeds, nosebleeds | Less common |
| Deep bleeding | Rare | Haemarthroses, muscle haematomas |
| Timing | Immediate | Often delayed |
Act on these findings
Fever after chemotherapy — neutropenic sepsis; antibiotics within 1 hour
Widespread petechiae or mucosal bleeding — urgent full blood count
Back pain with leg weakness in myeloma or cancer — possible cord compression; urgent MRI
Headache, visual change or confusion with very high counts — consider hyperviscosity
Presenting your findings
Model presentation
“I examined Mr Jones, a 68-year-old man, who appeared pale but comfortable at rest. There was no jaundice, and there were several bruises on both forearms. His pulse was 96 and regular. There was conjunctival pallor, with no gum hypertrophy or oral ulcers.
There was generalised lymphadenopathy, with non-tender, rubbery, mobile nodes in the cervical, axillary and inguinal regions, the largest 2 cm. The spleen was palpable 4 cm below the left costal margin, with a notch, and was dull to percussion. The liver was not enlarged and there was no bone tenderness. These findings are consistent with anaemia, generalised lymphadenopathy and splenomegaly, most likely from chronic lymphocytic leukaemia or lymphoma.”
Structure
| Stage | Include |
|---|---|
| Who | Name, age, setting |
| General | Pallor, jaundice, bleeding |
| Nodes | Groups and character |
| Abdomen | Spleen and liver |
| Conclude | Diagnosis and next steps |
Common pitfalls
Missing lymph node groups
Starting spleen palpation too high
Not rolling the patient onto the right side
Skipping the mouth
Forgetting bone tenderness
Not telling petechiae from bruises
To complete the examination
Full blood count and blood film
Reticulocyte count
Iron studies, B12 and folate
Haemolysis screen: LDH, bilirubin, haptoglobin, DAT
Coagulation studies
Serum protein electrophoresis
Sources
Checklist and learning content: supplied Haematological Examination Guide PDF, in the med study partner examination checklist format.
Further reading: Talley NJ, O’Connor S. Clinical Examination: A Systematic Guide to Physical Diagnosis. Elsevier. Hoffbrand AV, Moss PAH. Hoffbrand’s Essential Haematology. Wiley-Blackwell.
Always follow your own medical school’s marking criteria and local clinical policies. Made for learning, not for clinical decision-making.
Practice log
One row per attempt. Worksheet only; entries are not saved.
- Date: __________________
- Role: __________________
- Time: __________________
- Steps missed: __________________
- Feedback: __________________
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