Thrombocytopenia Evaluation Note

Date/Time: [Date and time of consult]

Setting: [inpatient consult / outpatient consult / e-consult]

Requesting Service: [Service and clinician name]

Consult Question: [Verbatim consult question if provided] (If not specified, state: Consult question not specified; evaluation requested for thrombocytopenia)

Data Sources: [patient interview / family / outside records / primary team / pharmacy MAR / interpreter used] (List all sources used; if information is limited, state Unknown and note steps taken to obtain collateral)

Patient Summary: [Age]-year-old [sex] with [key comorbidities] referred for thrombocytopenia; platelet nadir [value] and current [value]; [acute / subacute / chronic]; associated features: [bleeding / thrombosis / hemolysis / infection / pregnancy / liver disease / malignancy / recent heparin exposure / none].

Chief Concern and History of Present Illness

Chief Concern: [Reason for consultation, e.g., low platelets pre-procedure, bleeding, concern for HIT]

[HPI narrative in 1–3 paragraphs: Include explicit dates and values. Document when thrombocytopenia was first noted, prior baseline platelet counts, rate of decline, nadir, and current value. State whether isolated thrombocytopenia or part of pancytopenia. Summarize bleeding symptoms and severity; thrombotic symptoms such as limb swelling, catheter dysfunction, or ischemic symptoms; and constitutional symptoms. Document exposures around onset: new medications with start dates, recent antibiotics, OTC supplements, recent vaccination or viral illness. Include transfusion history with response to any platelet transfusions.] (If information is incomplete, state Unknown and document what records were reviewed or requested)

Bleeding Assessment

(This section is required and must be explicit even if entirely negative)

• Current bleeding [timeframe]: [skin (petechiae, purpura, ecchymoses with distribution) / mucosal (epistaxis, gingival) / GI / GU / pulmonary / intracranial symptoms / none]
• Severity and interventions: [frequency and volume; ED visits; transfusions; iron therapy; procedural interventions]
• Menstrual history: [cycle regularity; flooding or clots; pad/tampon count; functional impact] (Include if applicable)
• Historical bleeding phenotype: [prior surgeries, dental extractions, childbirth] with [normal hemostasis / abnormal bleeding]
• Bleeding risk modifiers: [anticoagulants / antiplatelets / NSAIDs / renal failure / liver disease / alcohol use / recent procedures / falls risk]
• Limitations: [history limited by…; collateral sought from…] (Include if applicable)

Medication Review and Heparin Exposure

Current medications with start dates: [List all, highlighting agents started within risk window for drug-associated thrombocytopenia]

• High-impact agents: [anticoagulants / antiplatelets / chemotherapy / checkpoint inhibitors / antibiotics (linezolid, TMP-SMX) / anticonvulsants / quinine-containing products]

Heparin exposure: (Must address even if negative)

• Exposure type: [UFH / LMWH] via [therapeutic / prophylactic / flushes / line locks / dialysis circuit / heparin-bonded catheter / none]
• First exposure this admission: [date / Unknown]; Prior 3 months: [dates and facilities / none / Unknown]
• If HIT considered: [percent platelet fall]; [timing from heparin exposure]; [new thrombosis present / absent]; [skin necrosis present / absent]; [alternative explanations] (Document pretest probability score if used; avoid definitive language if exposure details incomplete)
• Verification steps: [MAR review / pharmacy query / dialysis records / pending records requested]

Secondary Causes Screen

(Include only relevant categories; omit those that do not apply)

• HIV/HCV: [status if known / risk factors / testing ordered / Unknown]
• Recent viral illness or vaccination: [details]
• Autoimmune disease: [SLE / APS / other history or symptoms]
• Liver disease: [cirrhosis / abnormal LFTs / portal hypertension features]
• Splenomegaly: [exam findings / imaging findings / absent]
• Nutritional: [B12 or folate deficiency risk factors / testing status]
• Malignancy: [B symptoms / bone pain / weight loss / cancer history]
• Pregnancy/postpartum: [gestational thrombocytopenia vs hypertensive disorder features; delivery or neuraxial plans] (Include if applicable)

Relevant History

• Prior thrombocytopenia: [episodes and prior hematology evaluations / Unknown]
• Prior diagnoses: [ITP / TTP / HIT / DIC / cirrhosis / myelodysplasia / other]
• Splenectomy: [yes with date / no]
• Thrombotic history: [venous or arterial events; dates; treatments]
• Family history: [bleeding disorders / lifelong low platelets / none known]
• Alcohol use: [quantity and frequency]
• Exposures: [occupational toxins / tick exposures / radiation] (Include if relevant)

Physical Examination

• General: [appearance; distress level; hemodynamic stability]
• Skin: [petechiae / purpura / ecchymoses with distribution and extent / none]
• Mucosa: [oral and nasal findings]
• Neurologic: [focal deficits / confusion / headache / normal screen] (Expand if TMA or intracranial bleed concern)
• Abdomen: [hepatosplenomegaly present / absent by palpation or imaging]
• Lines/catheters: [site exam; erythema; tenderness; thrombosis signs]
• Pertinent negatives: [selected negatives that inform management]

Objective Data

• Platelet trend: [Date – Count] for baseline, nadir, and current (Select key inflection points)
• Other CBC: [Hemoglobin, MCV]; [WBC and differential]
• Peripheral smear: [reviewed / pending / not available]; Findings: [platelet clumping / schistocytes / blasts / giant platelets / other] (If not yet reviewed, state explicitly)
• Coagulation: [PT/INR; aPTT; fibrinogen; D-dimer] (Include if indicated)
• Hemolysis/TMA labs: [LDH; haptoglobin; indirect bilirubin; reticulocyte count] (Include if indicated)
• Renal: [creatinine; urinalysis findings]
• Secondary cause labs: [HIV; HCV; B12; folate; LFTs]
• Imaging: [spleen size; thrombosis imaging; other]
• Planned procedures: [procedure and timing]

Assessment

Problem statement: [Acute / Subacute / Chronic], [isolated / multilineage] thrombocytopenia; [symptomatic / asymptomatic]. Current platelet [value] with [rising / stable / falling] trajectory. Bleeding [present / absent]; risk modifiers: [anticoagulation / planned procedures / uremia / liver disease].

Mechanism-based differential:

• Spurious: [EDTA clumping; platelet satellitism; lab artifact]
• Decreased production: [marrow failure; infiltration; chemotherapy; infection; nutritional deficiency]
• Increased destruction: [ITP; drug-dependent antibodies; autoimmune]
• Consumption: [HIT; TMA/TTP; DIC; sepsis]
• Sequestration: [hypersplenism; portal hypertension]
• Dilutional: [massive transfusion or fluid resuscitation] (Include if applicable)

Cannot-miss triage:

• TMA/TTP: [suspected / not suspected] – [reasoning based on hemolysis markers, smear, neurologic/renal involvement]
• HIT: [suspected / not suspected] – [timing, percent fall, thrombosis, pretest probability]
• DIC: [suspected / not suspected] – [coagulation profile and clinical context]
• Marrow failure/malignancy: [suspected / not suspected] – [cytopenias, blasts, constitutional symptoms]

Leading diagnosis: [State leading consideration with explicit reasoning] (Avoid definitive labels unless diagnostic criteria are met and key alternatives addressed)

Plan

Immediate Actions

• Level of care: [ICU / step-down / floor / outpatient]
• Precautions: [bleeding precautions; activity restrictions]
• Medication holds: [anticoagulants / antiplatelets / NSAIDs held] (Document thrombosis risk consideration)

Diagnostic Plan

• Validate platelet count: [repeat CBC in citrate tube if clumping suspected; manual smear review]
• Etiology testing: [HIT immunoassay with pretest probability documented; hemolysis/TMA workup; HIV, HCV, B12, folate as appropriate]
• Bone marrow biopsy: [indicated with timing / deferred with rationale]

Therapeutic Plan

• Contingencies: [If platelet count falls below threshold, then…; If bleeding develops, then…; If procedure planned, target platelet goal by strategy]
• Etiology-specific therapy: [steroids / IVIG / TPO-RA / plasma exchange / discontinue offending agent / other] (Include only if indicated)

Platelet Transfusion Guidance

• Transfusion indicated now: [Yes / No] – [rationale]
• Procedure thresholds: Prophylaxis non-bleeding <10K; Central line <20K; LP <40K; Major surgery <50K; Neuraxial <80K; Neurosurgery <100K (Document local policy if different)
• Cautions: [TTP – avoid unless life-threatening hemorrhage; HIT – avoid routine transfusion unless active bleeding or procedure need]

Anticoagulation

[If thrombosis present or HIT/TMA suspected: agent selection; dose; platelet threshold for holding/resuming; bleeding risk mitigation] (Include if applicable)

Monitoring and Follow-up

• Platelet monitoring: [frequency and setting]
• Return precautions: [new or worsening bleeding; neurologic symptoms; melena; hematuria; uncontrolled epistaxis]
• Follow-up: [timeframe; responsible clinician]

Communication

• Patient/family discussion: [risks, precautions, diagnostic uncertainty, plan]
• Primary team: [recommendations relayed; medication guidance; who follows pending results]