HISTORY. Question the patient (or the parents of the patient, as appropriate) about any exposure to radiation, chemicals, viruses, and medications, including chemotherapy for cancer. Determine the adult patient's occupation, and pay particular attention to radiation exposure of healthcare workers, workers in a power plant, or those serving in the military. Often, the patient describes a sudden onset of high fever and signs of abnormal bleeding (increased bruising, bleeding after minor trauma, nosebleeds, bleeding gums, petechiae, and prolonged menses). Some patients report increased fatigue and malaise, weight loss, palpitations, night sweats, and chills. Parents of children with leukemia often report a series of recurrent pulmonary, urinary tract, and perirectal infections. Patients may also complain of abdominal or bone pain.

PHYSICAL EXAMINATION. The patient appears acutely ill, short of breath, and pale. Children are often febrile. When you inspect the lips and mouth, you may note bleeding gums and ulcerated areas of the mouth and throat. On palpation, you may feel lymph node swelling and enlargement of the liver and spleen. When you auscultate the patient's lungs, you may hear decreased breath sounds, shallow and rapid respirations, a rapid heart rate, and a systolic ejection murmur.

PSYCHOSOCIAL. When the diagnosis of acute leukemia is made, patients, parents, and significant others are shocked and fearful. If the patient is a child, determine the patient's stage of development and his or her relationship with parents, caregivers, or grandparents. If the patient is an adult, determine the patient's job, childcare, and financial responsibilities. Assess the patient's home situation to determine the possibility of home healthcare. Determine the support systems available to the patient, including emotional, religious, financial, and social support.

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