Thrombocytopenia

 Outpatient

.fname has been referred for further evaluation and management of thrombocytopenia.

On review of records, he/she had a normal platelet count until -date. OR We have no record of last known normal platelet count.

On- date- platelet counts were (low/normal) at *. Since then there has been a gradual drop over a period of * months. The most recent platelet counts are *.

Hemoglobin and white count are normal.

Clinically, the patient denies bleeding from nose, mouth, gums or cutaneous bleeding. There is no history of rectal bleeding or melena. No history of vaginal bleeding or hematuria.

No constitutional symptoms such as weight loss, weight gain, fever, chills, abnormal lumps. Full 13 system review was as noted below. No recent vaccinations.

No history of infections such as hepatitis C or Helicobacter pylori. No history of risk factors for HIV such as unprotected sexual intercourse or needle sharing. He is agreeable to testing for these 3 infections as part of the work up.

No history of liver disease. LFT are normal. Prior abdominal imaging in *date showed no evidence of splenomegaly, or liver cirrhosis on ultrasound. The platelet count at the time of the imaging was low at *. History of alcohol intake:

No history of tobacco or recreational drug use. Marijuana* 

The patient is not pregnant. There is no family history of blood disorders or bleeding history. No family members with a history of splenectomy. No history of blood transfusion, heparin exposure, cardiac or other surgical procedures in the last 3 months.

All medications were reviewed. He was not temporally initiated on a new medication prior to the onset of thrombocytopenia.  Over the counter medications were reviewed.*

There is no history of malignancy or autoimmune condition personally or in the family.

Clinical exam:

Conjunctival bleeding

Skin petechiae/ purpura

Oral mucosa: wet purpura

Abdomen: palpable liver and or spleen

Signs of chronic liver disease

A/P:

.age yo .gender with isolated thrombocytopenia of gradual onset since *. No clinical evidence of bleeding. No associated anemia or WBC abnormalities. No hx of drug use, excess alcohol use. No hx of malignancy, autoimmune disease, new medication or liver disease. No hx of infections, recent blood transfusion, cardiac or surgical procedures.

Ddx: ITP, drug induced thrombocytopenia.

Investigations:

• CBC, peripheral smear review, quantitative immunoglobulin, B12 level
• Infection testing: hepatitis C, HIV, H. pylori
• Bone marrow exam: if older 60 yr, treatment with steroids planned, rapid down trend in platelet count, anemia or WBC count issues to rule out MDS.
• US abdomen -
• If anemia- baseline anemia work up, B12 level, ferritin, retic count 
• ABO, DAT

Inpatient: reference

.fname was admitted to the hospital on * for complaints of *.  Information was obtained by review of records. 

Last normal platelets:

Sudden or gradual drop in platelets since: 

Prior to this, the patient was started on * medication/ chemotherapy. hx of antibiotic or heparin ( 4T score)

No history of recent surgery, cardiac procedure, or blood transfusion. No hx of vaccination.

Current medications including antibiotics with start date:

Summary of initial work up:

• DIC panel: fibrinogen, D dimer, FDP ( use ISTH scoring system)
• Peripheral smear : Examine smear- 
• clumping, giant plt--> true thrombocytopenia
• RBC: schistocytes, spherocytes,  nucleated RBC, RBC clumping, 
• WBC: blasts, toxic granulations, atypical lymphocytes, neutrophilia
• B12, ferritin
• PT, PTT
• Blood cultures
• Hepatitis C, HIV
• ABO DAT

A/P Top diagnosis:  sepsis, drug-induced thrombocytopenia, immune thrombocytopenia, or surgery

Rule out life threatening conditions:  Identify if actively bleeding, new thrombosis, multiorgan failure, neurologic dysfunction, DIC,  post op or on dialysis

Ddx: Life threatening diagnosis

• Sepsis-induced thrombocytopenia (check blood cultures and lactate)
• Heparin-induced thrombocytopenia
• Thrombotic thrombocytopenia purpura or hemolytic uremic syndrome (which leads to fragmented red blood cells and an increased LDH)
• Drug-induced immune thrombocytopenia
• Primary immune thrombocytopenia (ITP) with bleeding (very unusual in a hospitalized patient who doesn’t have a previous diagnosis of ITP)
• Acute leukemia
• Posttransfusion purpura (very rare)