REFREC010

HAEMATOLOGY REFERRAL RECOMMENDATIONS

Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines Haematology can be categorised A thorough history and physical examination Specific treatments depend on the Circumstances for referral are indicated into the following disorders: is required to determine the specific diagnoses identified, as noted below. below with reference to the appropriate diagnosis (see below). Full blood count and specialty/specialties. • Acute Malignant Disorders other appropriate investigations are • Anaemias necessary for Haematological referrals. • Bleeding disorders • Chronic Malignant Disorders • Miscellaneous • Thrombotic disorders

Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines Acute Malignant Disorders Acute leukaemia/lymphoma KEY POINTS: Ring Haematologist on call at hospital. Immediate referral with a view to admission Any suspicion of acute leukaemia/lymphoma – Category 1. requires urgent discussion with Haematologist For example: 1. FBC suggesting acute leukaemia/lymphoma. 2. Suggestive clinical signs, eg bleeding gums, splenomegaly, PUO lymphadenopathy.

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Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines Anaemia KEY POINTS: GI tract blood loss must be excluded in • Persistent unexplained anaemia – • Duration of anaemia. all cases of iron deficiency. Category 3 or 4. • Previous anaemia assessment. Most iron deficiency does not require • Anaemia refractory to iron and • Family history. Specialist Haematology Assessment. B12/folate – Category 3. • Bleeding history especially menstrual Low B12 requires exclusion of • Haemolytic anaemia of any cause – loss. pernicious anaemia and other causes Category 2 or 3. • Dietary history. of malabsorbtion. • Drug history. Gastroenterology referral should be • Exclude surgical causes of iron considered. deficiency.

Investigations: • FBC/ESR/Coombs test. • B12/red cell folate. • Iron studies including ferritin and Transferrin saturation. • Reticulocytes. • Renal function. • LFTs. • Immunoglobins and serum electrophoresis. • MSU.

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Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines Bleeding disorders Familial Conditions KEY POINTS: If acutely bleeding ring Haematologist • Acute bleeding should be referred for • Detailed family history on-call at Hospital for advice re admission – Category 1. • Detailed type of bleeding eg. management. • Pre-surgery assessment – refer Mucocutaneous, joint bleeding or Category 4. menorrhagia • Carrier status assessment – Category 4.

Investigations: • Coagulation screen (PT PTT TCT). • Factor assay appropriate to family history eg. Haemophilia A-Factor VIII, Von Willebrand’s disease VWF screen. Bleeding disorders of uncertain KEY POINTS: If actively bleeding stop NSAID and • Acute bleeding should be referred for cause • May have a family history aspirin. admission – Category 1. • Type of bleeding eg. Mucocutaneous, If acutely bleeding ring Haematologist • Pre-surgery assessment – refer joint bleeding, menorrhagia on-call at hospital for advice re Category 4. • Drug history management. • Carrier status assessment – Category 4. • Post-surgery bleeding? • Post-trauma bleeding? Mild von Willebrand’s Disease may be a cause of menorrhagia, but Investigations: gynaecological causes should also be • Coagulation screen (PT PTT TCT). excluded. • FBC. • LFTs. • Renal function. • Immunoglobins and serum electrophoresis. • MSU.

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Thrombocytopenia KEY POINTS: Discontinue NSAID and aspirin unless • Patients with a count less than 20 x • Duration. clear indication to continue. 109/L should be referred for immediate • Detailed past history, eg liver, Review drug history and stop offending admission assessment – Category 1. autoimmune. agents if possible. • Patients with a count less than 50 x • Drug history. 109/L refer for urgent outpatient • Alcohol history. assessment – Category 2 • Recent Vaccination history. • Stable/mild thrombocytopenia refer for outpatient assessment – Category 4. Investigations: • FBC, ESR, Iron studies B12/Folate. • LFTs. • Renal function. • Immunoglobins and serum electrophoresis. • MSU. • ANF/autoimmune screen/platelet antibodies.

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Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines Chronic Malignant Disorders Chronic Myeloid Leukaemia KEY POINTS: Ring Haematologist on call at hospital with a • Patients with very high white cell counts view to immediate review – Category 1. (>60 x 109/1) and/or massive splenomegaly. Discuss with • Refer to urgent outpatient clinic – Haematologist urgently. Category 2 • Less advanced cases can be seen (Discuss with Haematologist) urgently in outpatient clinics.

Chronic Lymphocytic Leukaemia KEY POINTS: • Referral Category 4 • Most cases are early disease with • Progressive disease with anaemia, normal haemoglobin and platelets and lymphadenopathy, splenomegaly and no splenomegaly. thrombocytopenia require referral urgent – Category 2. • Complications of haemolysis requires immediate referral – Category 1.

Myelodysplastic disorders KEY POINTS: Patients with active infection and/or • Acutely unwell patients secondary to • This is a spectrum of disorders ongoing bleeding discuss with neutropenia or thrombocytopenia presenting with unexplained cytopenias Haematologist. require immediate admission – Category of varying severity. 1. • A bone marrow examination is required • Uncomplicated patients outpatient to confirm diagnosis. referral – Category 3.

Myeloproliferative Disorders KEY POINTS: • Patients with clinical hyperviscosity, • As above, this is a spectrum of thrombosis or bleeding for admission – disorders presenting with unexplained Category 1. raised haemoglobin, platelets and • Uncomplicated refer to outpatient neutrophils. assessment – Category 4.

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Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines Miscellaneous Aplastic anaemia KEY POINTS: (An urgent assessment and bone • Most of these referrals are outpatients – Red cell aplasia • Consider drug induced causes. marrow may be required – discuss with Category 3. Haematologist). • Severe cytopenia, platelets < 30, neutrophils < 1 – contact Haematologist.

Hereditary Haemolytic Anaemias KEY POINTS: • Most referrals are Outpatients - eg. Thalassemia, Hereditary • Family History. Category 3 or 4 Spherocytosis Chronic Eosinophilia KEY POINTS: • Uncomplicated cases – Category 3 or 4

Iron Overload KEY POINTS: • Most referrals are Outpatient – Category ?Haemochromatosis • Family history. 3 or • Exclude chronic disease. 4.

Investigations: • Iron studies, include Ferritin and Transferrin Saturation. • Genetic testing.

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Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines Thrombotic disorders Familial Thrombotic Disorders KEY POINTS: Anticoagulation therapy should be • Acute thrombotic event requires urgent • Detailed family history. continued as previously assessment query admission to acute • Detailed type of thrombosis eg. Venous or recommended until Haematology medical team – Category 2. arterial review. • Assessment required prior to planned • Recurrent or single event? If pregnant will require a joint surgery or pregnancy – Category 4. • Recent surgery/trauma. approach between Haematologist, • Pregnancy. Obstetrician or Physician • Drug history including oral contraceptive or specialising in disorders of HRT. pregnancy. • Smoking history.

Investigations: • FBC/ESR. • LFT’s. • Renal function. • Coagulation screen. • Thrombophilia screen.

Thrombotic disorders of uncertain KEY POINTS: Anticoagulation therapy should be • Acute thrombotic event requires urgent causes • May have a family history. continued as previously assessment query admission to acute • Type of thrombosis eg. DVT, arterial. recommended until Haematology medical team – Category 2. • Drug history including oral contraceptive or review. • Assessment required prior to planned HRT. If pregnant will require a joint surgery or pregnancy – Category 4. • Post-surgery thrombosis? approach between Haematologist, • Post-trauma thrombosis? Obstetrician or Physician • Pregnancy associated thrombosis? specialising in disorders of • Important group aged under 40 recurrent pregnancy. unexplained thrombosis. • Smoking history.

Investigations: • Coagulation screen. • FBC/ESR. • LFTs. • Renal function. • Thrombophilia screen.

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Myeloma/Plasmacytoma KEY POINTS: • Acutely unwell patients secondary to • Bone pain. hypercalcaemia, cord compression, • Anaemia. renal failure or hyperviscosity require • Hypercalcaemia. immediate admission – Category 1. • Cord compression. • Uncomplicated patients outpatient • Renal failure. referral Category 2. • Hyperviscosity.

Investigations: • FBC/ESR. • Reticulocytes. • Renal function. • LFTs. • Calcium. • Immunoglobins and electrophoresis. • Urine/Bence-Jones protein. • Bone marrow. • X-ray of painful areas and skeletal survey.

Paraproteinaemia – uncertain Investigations: • Uncomplicated patients – Category 3. significance • FBC/ESR/Reticulocytes. • Renal function. • LFT’s. • Calcium. • Immunoglobulin and serum electrophoresis. • Urine/Bence Jones Protein.

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