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Clinical Assessment Table 98.3 presents assessment and management guidelines for leukemia in the ED The evaluation should begin with a thorough history and physical examination The history should focus on the time frame in which symptoms developed and should screen for the complications described above Assess airway patency, which may be threatened in the setting of a mediastinal mass Assessment of the patient’s breathing should include attention to the respiratory rate and oxygenation, both of which can become compromised in the setting of anemia, leukostasis, congestive heart failure, and pulmonary infection In assessing the patient’s circulation, establish intravascular access and include an assessment for evidence of SVC syndrome The physical examination should include an evaluation for lymphadenopathy and hepatosplenomegaly Signs of soft tissue infiltration by leukemia cells should be explored, including skin infiltration (leukemia cutis) and testicular enlargement in male patients A thorough neurologic examination is essential to screen for cord compression and CNS effects of the leukemia Any abnormalities on neurologic examination warrant further imaging to determine whether a neurologic complication of the leukemia has occurred Laboratory evaluation should begin with a complete blood count (CBC), WBC differential, and peripheral blood smear to be reviewed by a hematologist– oncologist or pathologist Automated differentials might count leukemic blasts as either atypical lymphocytes or monocytes so abnormal numbers of these cell types should raise concern for leukemia Flow cytometry analysis can provide important diagnostic clues by analyzing the proteins of the blast cell surface Specific diagnosis requires a bone marrow aspirate, which is not routinely performed in the ED and should be done in consultation with an oncologist
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