Station 35

Micheal Hollaway

Age: 39 years old male

Examiner

Station List
Doctor
Patient
Full Case

Marking Scheme

Data Gathering and Diagnosis 

  • Ask why the blood test was arranged (to understand the initial presenting symptoms or concerns)
  • Ask when the patient first noticed the bruising, including the location of the bruises and whether they are getting worse, improving, or unchanged.
  • Ask about any abnormal bleeding, including nosebleeds, bleeding gums, vomiting blood, dark stools, rectal bleeding, or blood in the urine.
  • Screen for systemic symptoms suggestive of possible haematological malignancy, such as unintentional weight loss, night sweats, fever, or bone pain.
  • Ask about any abdominal symptoms, including pain, swelling, or noticeable lumps or bumps.
  • Ask about recent or past infections, including flu-like symptoms, sore throat, or gastrointestinal illness.
  • Ask about use of over-the-counter medications, particularly NSAIDs, which may contribute to drug-induced thrombocytopenia.
  • Ask about any family history of bleeding disorders or blood cancers.
  • Ask about social history, including smoking, alcohol use, and occupation.
  • Explore ICE – the patient’s Ideas, Concerns, and Expectations.
  • Provide a working diagnosis of thrombocytopenia
  • Provide a working diagnosis of thrombocytopenia, likely linked to a recent viral illness (e.g. sore throat), suggestive of immune thrombocytopenic purpura (ITP).

Example of explanation to patient​

Michael, your blood test shows that your platelet count is lower than normal—this condition is called thrombocytopenia. Platelets are the part of your blood that help it to clot, so when the count is low, it can lead to symptoms like bruising or bleeding, which you’ve been experiencing.

There are many reasons why your platelets might be low, and I want to reassure you that this can sometimes be due to minor issues, such as certain infections or medications.  

You mentioned that you had a sore throat a few weeks ago, and it’s possible that your immune system reacted to that infection and temporarily started targeting your platelets—a condition known as Immune Thrombocytopenic Purpura (ITP). This is something that can be managed. 

That said, I also understand your concern about leukaemia, especially with your family history. It’s important to take this seriously, and we’ll be doing further investigations to rule out any serious causes. That includes arranging a peripheral blood smear (or blood film) to look at your blood cells more closely, along with a range of blood tests such as Liver Function Tests (LFTs), clotting profile, Kidney function test (Urea and Electrolytes), vitamin B12, folate, and ferritin levels—if you’re happy to go ahead with that.

Depending on the results, if the platelet count remains low or we spot anything unusual, we’ll arrange for you to be seen by a haematologist—a blood specialist—for further assessment.

But I do want to reassure you again: not everyone with a low platelet count has leukaemia, and there are treatable and temporary causes, especially in someone young and otherwise well like yourself

Management

  • Arrange an urgent peripheral blood smear (blood film), along with additional blood tests including Liver Function Tests (LFTs), clotting profile, Urea and Electrolytes (U&Es), vitamin B12, folate, ferritin, and HIV and hepatitis screen (if there is clinical suspicion of an infectious cause).
  • Advise the patient to minimise risk of injury or trauma due to the increased bleeding risk associated with low platelet count.
  • Book a follow-up appointment in one week to review the results and discuss the next steps.
  • Explain that if platelet levels continue to fall or the blood film is inconclusive, the case may then be discussed with a haematologist for further input — but emphasise that this is not necessary at this stage until initial investigations are completed.
  • Provide safety netting advice: advise the patient to recontact the surgery or seek urgent medical attention if they develop worsening symptoms, such as increased bruising or bleeding, or any symptoms which could indicate anaemia including, dizziness, worsening fatigue breathlessness, chest pain, or palpitations.

Learning point from this station: ​

Thrombocytopenia, or a low platelet count, has a wide range of causes that can broadly be classified into three main categories:

Reduced platelet production – often due to bone marrow disorders (e.g. leukaemia, aplastic anaemia).

Increased platelet destruction – which may be immune-mediated, as in Immune Thrombocytopenic Purpura (ITP).

Increased platelet sequestration – typically due to splenomegaly.

ITP should be suspected in patients with isolated thrombocytopenia, particularly following a recent viral illness. In ITP, platelets are otherwise normal but are destroyed by the immune system in response to an unknown trigger. It may be primary (occurring alone) or secondary (associated with other conditions).

Leukaemia may present with pancytopenia and is often associated with red flag symptoms such as unexplained fever, night sweats, weight loss, bone or joint pain, lymphadenopathy, and persistent or recurrent infections.

It is important to ask about over-the-counter medications, especially NSAIDs, which are a common and sometimes overlooked cause of thrombocytopenia.

Management depends on the severity of thrombocytopenia and associated findings:

Immediate same-day hospital referral for:

  • Platelet count <20 × 10⁹/L
  • Any active bleeding, regardless of count

Urgent referral (usually within 2 weeks) if:

  • Platelets <50 × 10⁹/L
  • Platelets 50–100 × 10⁹/L and associated with: pancytopenia, splenomegaly , lymphadenopathy, pregnancy or planned surgery or procedures

If platelet count is 50–100 × 10⁹/L without other risk factors, repeat the FBC in 1–2 weeks.

If platelet count remains <100 × 10⁹/L persistently and is unexplained on at least two occasions (4–6 weeks apart), refer to haematology in line with local guidelines.

If the platelet count is between 100–150 × 10⁹/L with no clear underlying cause, repeat the full blood count in 4–6 weeks.

Refer to haematology if the platelet count continues to decline, remains persistently low without explanation, is accompanied by other haematological abnormalities, or if the patient becomes clinically unwell.

Note that “Unexplained” refers to cases where the patient’s symptoms or signs have not resulted in a clear diagnosis following the initial assessment in primary care, which includes history taking, physical examination, and any relevant investigations carried out by the clinician.

Further reading