Hepatosplenomegaly (Haematological) 

 

Thank you for asking me to examine Harry, who presented with abdominal fullness.

 

The most salient finding on examination was hepatosplenomegaly/splenomegaly with/without features of chronic liver disease and portal hypertension, and with/without widespread lymphadenopathy, which is most consistent with a myeloproliferative/lymphoproliferative disease.

 

I will now present my findings in full with further commentary on the potential aetiology.

 

On general inspection, Harry was comfortable with no evidence of jaundice or bronze pigmentation. He did / did not appear cachectic.

 

On inspection of the abdomen there was / was not any surgical scars. There was / was not obvious distension. There was / was not prominent veins.

 

On palpation, there was a palpable mass extending from the left upper quadrant inferiorly and medially to ____ cm below the costal margin and / without crossing the midline. There was no palpable upper edge, it moved inferomedially on inspiration, and there was a palpable notch, and hence believe it is consistent with splenomegaly. It was / was not tender and had a smooth texture.

 

There was associated hepatomegaly with an estimated liver span of ____ on percussion. It was non-tender and had a smooth / irregular /pulsatile edge.

 

On percussion, there was / was not shifting dullness, suggesting ascites.

 

Bowel sounds were normal / absent.

 

On further examination to determine an aetiology and complications:

• There were / were not clear stigmata of chronic liver disease, more specifically findings of clubbing, leukonychia, palmar erythema, small muscle wasting, Dupuytren’s contracture, hepatic flap, spider naevi, and gynaecomastia

• From a haematological perspective, there was / was not lymphadenopathy in epitrochlear, axillary, cervical or inguinal nodes.

  • There were / were not petechiae and ecchymoses on the arms and legs.

  • Scratch marks were / were not evident (myeloproliferative disease).

  • There was / was not scleral icterus, conjunctival pallor or plethora (polcythaemia).

  • The gums were normal, and the tonsils were not enlarged.

  • There was / was not bony tenderness.

  • There was / was not a Hickman’s scar.

• From a CTD perspective;

  • There was / was not evidence of connective tissue disease such as rheumatoid arthritis or systemic lupus erythematosus, and typically these cause small splenomegaly.

• Given it was non-tender, I consider viral infections less likely. There was also no stigmata of infective endocarditis.

 

In summary, Harry presented with abdominal fullness. My findings are consistent with splenomegaly, and in the absence of chronic liver disease stigmata, I think the most likely aetiology of moderate to massive splenomegaly is a myelo/lymphoproliferative malignancy such as myelofibrosis/CML/CLL. There is/isn’t evidence of complications such as anaemia, thrombocytopenia, and secondary gout. In terms of treatment, there was no Hickman’s scar suggesting intensive chemotherapy or conditioning for an allograft

 

Other differentials include:

• Chronic liver disease with portal hypertension

• Haematological:

  • Myeloproliferative - myelofibrosis, CML, PRV, ET

  • Lymphoproliferative - lymphoma, CLL, leukaemia

  • Thalassaemia

• CTD - RA, SLE

• Infiltrative - amyloidosis, sarcoidosis

• Infective - viral, bacterial, malaria

I would like to proceed from here by:

• Confirming my diagnosis with an ultrasound