CPAC HAEMATOLOGY 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 with into the following disorders: is required to determine the specific diagnoses identified reference to the appropriate diagnosis. specialty/specialties. • Acute malignant disorders • Anaemias Full blood count and other appropriate • Bleeding disorders investigations are necessary for • Chronic Malignant Disorders Haematological referrals and these are • Miscellaneous outlined below. • thrombocytopenia Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines Acute Malignant Disorders Acute leukaemia/lymphoma KEY POINTS: Contact Haematologist on call at Immediate referral with a view to admission Any suspicion of acute leukaemia/lymphoma hospital. requires urgent discussion with Haematologist. For example: 1. FBC suggesting acute leukaemia/lymphoma. 2. Suggestive clinical signs, eg bleeding gums, splenomegaly, pyrexia of unknown origin, lymphadenopathy. Updated December 2014 Page 1 of 7 CPAC HAEMATOLOGY Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines Anaemia KEY POINTS: • Duration of anaemia. GI tract blood loss must be excluded in • Persistent unexplained anaemia – • Previous anaemia assessment. all cases of iron deficiency. Most iron Routine. • Family history. deficiency does not require Specialist • Anaemia refractory to iron and • Bleeding history especially menstrual Haematology Assessment. B12/folate – Routine. loss. • Haemolytic anaemia of any cause – • Dietary history. Low B12 requires exclusion of Routine. • Drug history. pernicious anaemia and other causes • Exclude surgical causes of iron of malabsorption. Gastroenterology deficiency. referral should be considered. 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. Updated December 2014 Page 2 of 7 CPAC HAEMATOLOGY 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. • Detailed type of bleeding eg. management. • Pre-surgery assessment – refer Routine. Mucocutaneous, joint bleeding or • Carrier status assessment – Routine. menorrhagia 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. • Type of bleeding eg. Mucocutaneous, If acutely bleeding ring Haematologist • Pre-surgery assessment – refer Routine. joint bleeding, menorrhagia on-call at hospital for advice re • Carrier status assessment – Routine. • Drug history management. • Consider post-surgery bleeding • Consider 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. Updated December 2014 Page 3 of 7 CPAC HAEMATOLOGY Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines Thrombocytopenia KEY POINTS: Discontinue NSAID and aspirin unless • Patients with a count less than 20 x 9 • Duration. clear indication to continue. 10 /L should be discussed with a • Detailed past history, eg liver, Review drug history and stop offending Haematologist t autoimmune. agents if possible. • Patients with a count less than 50 x 9 • Drug history. 10 /L refer for urgent outpatient • Alcohol history. assessment – Urgent • Recent Vaccination history. • Stable/mild thrombocytopenia refer for outpatient assessment – Routine. Investigations: • FBC, ESR, Iron studies B12/Folate. • LFTs. • Renal function. • Immunoglobins and serum electrophoresis. • MSU. • ANF/autoimmune screen/platelet antibodies. 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. (>60 x 109/1) and/or massive splenomegaly. Discuss with • Refer to urgent outpatient clinic – Haematologist urgently. Discuss with Haematologist • Less advanced cases can be seen urgently in outpatient clinics. Chronic Lymphocytic Leukaemia KEY POINTS: • Referral Routine • Most cases are early disease with • Progressive disease with anaemia, normal haemoglobin and platelets and lymphadenopathy, splenomegaly and no splenomegaly. thrombocytopenia require referral urgent – Semi-urgent. Complications of haemolysis requires immediate discussion with Haematologist Updated December 2014 Page 4 of 7 CPAC HAEMATOLOGY Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines 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. of varying severity. • A bone marrow examination is required • Uncomplicated patients outpatient to confirm diagnosis. referral – Routine. Myeloproliferative Disorders KEY POINTS: • Patients with clinical hyperviscosity, • As above, this is a spectrum of thrombosis or bleeding for admission disorders presenting with unexplained raised haemoglobin, platelets and • Uncomplicated refer to outpatient neutrophils. assessment – Routine. 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 Routine. Haematologist). • Severe cytopenia, platelets < 30 neutrophils < 1 – contact Haematologist. Hereditary Haemolytic Anaemias KEY POINTS: • Most referrals are Outpatients - Routine eg. Thalassemia, Hereditary • Family History. Spherocytosis Chronic Eosinophilia KEY POINTS: • Uncomplicated cases – Routine Iron Overload KEY POINTS: Most referrals are Outpatient – Routine Consider Haemochromatosis • Family history. • Exclude chronic disease. Investigations: • Iron studies, include Ferritin and Transferrin saturation. • Genetic testing. Updated December 2014 Page 5 of 7 CPAC HAEMATOLOGY Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines Thrombotic disorders Familial Thrombotic Disorders KEY POINTS: • Detailed family history. Anticoagulation therapy should be • Acute thrombotic event requires urgent • Detailed type of thrombosis eg. Venous or continued as previously assessment query admission to acute arterial recommended until Haematology medical team – Semi-urgent. • Recurrent or single event review. • Assessment required prior to planned • Recent surgery/trauma. surgery or pregnancy – Routine. • Pregnancy. If pregnant will require a joint • Drug history including oral contraceptive or approach between Haematologist, HRT. Obstetrician or Physician • Smoking history. specialising in disorders of pregnancy. Investigations: • FBC/ESR. • LFT’s. • Renal function. • Coagulation screen. • Thrombophilia screen. Thrombotic disorders of uncertain KEY POINTS: causes • May have a family history. Anticoagulation therapy should be • Acute thrombotic event requires urgent • Type of thrombosis eg. DVT, arterial. continued as previously assessment query admission to acute • Drug history including oral contraceptive or recommended until Haematology medical team HRT. review. • Post-surgery thrombosis • Assessment required prior to planned • Post-trauma thrombosis If pregnant will require a joint surgery or pregnancy – Routine. • Pregnancy associated thrombosis? approach between Haematologist, • Important group aged under 40 recurrent Obstetrician or Physician unexplained thrombosis. specialising in disorders of pregnancy. • Smoking history. Investigations: • Coagulation screen. • FBC/ESR. • LFTs. • Renal function. • Thrombophilia screen. Updated December 2014 Page 6 of 7 CPAC HAEMATOLOGY Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines Myeloma/Plasmacytoma KEY POINTS: • Acutely unwell patients secondary to • Bone pain. hypercalcaemia, cord compression, • Anaemia. renal failure or hyperviscosity require • Hypercalcaemia. immediate discussion with • Cord compression. Haematologist. • Renal failure. • Hyperviscosity. • Uncomplicated patients outpatient referral Semi-urgent. 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 – Routine. significance • FBC/ESR/Reticulocytes. • Renal function. • LFT’s. • Calcium. • Immunoglobulin and serum electrophoresis. • Urine/Bence Jones Protein. Updated December 2014 Page 7 of 7 .