HISTORY. Often, symptoms of chronic leukemia are nonspecific and vague. In CML, sometimes the first symptom is a dragging sensation caused by extreme splenomegaly, or it may be left upper quadrant pain that is caused by a splenic infarct. In CLL, swollen lymph nodes or enlarged liver and spleen may cause discomfort.

Elicit a history of signs and symptoms such as fatigue and anorexia. Some patients may report any of the following symptoms that are associated with either anemia or increased metabolism because of rapid cell turnover: weakness, weight loss, dyspnea, decreased stamina during exercise, or headache. Ask about bleeding from the gums or nose or easy bruising (signs of thrombocytope-nia), abdominal discomfort, or pain in the chest and rib areas. Question the patient about recent weight loss or appetite loss; blood in the urine; or black, tarry stools. Bone and joint tenderness may occur from marrow involvement. Determine if the patient has been running a low-grade fever. Take an occupational history to determine possible exposure to radiation or carcinogenic chemicals.

PHYSICAL EXAMINATION. Observe the patient's general appearance for pallor, and inspect for ecchymoses and bruises. Examine the patient's eyes for retinal hemorrhage. Palpate the lymph nodes to determine the presence of lymphadenopathy and palpate the abdomen for enlargement of the spleen or liver. Palpate the patient's thorax for signs of sternal or rib tenderness, which may be indications of infiltration of the periosteum. Inspect the ankles for edema. Note a low-grade fever. Examine the skin for macular to nodular eruptions, signs of skin infiltrations, bruising, and opportunistic fungal infections. Pulmonary infiltrates may appear when lung parenchyma is involved. Assess the patient's breathing for dyspnea. Auscultate the heart for signs of tachycardia and palpitation.

PSYCHOSOCIAL. Despite advances in treatment and cure, the diagnosis of cancer is an emotionally laden one. Determine the past coping mechanisms used to manage situations of severe stress. Assess the patient's home situation to determine the possibility of home healthcare. Assess the support systems available, including emotional, religious, financial, and social.

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