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Nishant Rajendra Tiwari – My 12-Step Thrombocytopenia Workup 
Nishant Rajendra Tiwari/X
Nov 30, 2025, 14:46

Nishant Rajendra Tiwari – My 12-Step Thrombocytopenia Workup 

Nishant Rajendra Tiwari, Hematology-Oncology Fellow at OU Health Stephenson Cancer Center, posted on X:

”My 12-Step Thrombocytopenia Workup
(Not Medical Advice)

1. Review baseline counts first. Rule out pseudothrombocytopenia.

2. Evaluate for critical conditions: TTP, HIT, or DIC?
• Assess heparin exposure – Calculate 4T score.
• Peripheral smear for schistocytes.
• Check LDH/Haptoglobin/Bilirubin, PT/aPTT/Fibrinogen.

3. Assess for acute leukemia or bone marrow involvement?
• Examine peripheral smear for abnormal/neoplastic cells.
• Consider imaging if clinically indicated.
• Do we need a bone marrow exam?

4. Active life-threatening bleeding? Do we need a platelet transfusion?

5. Review drug-induced thrombocytopenia. Always consult latest literature for implicated medications.

6. Investigate secondary causes:
• Nutritional deficiencies: B12, Folate, Copper, Zinc.
• Infections: HIV, Hepatitis, CMV, EBV, HSV (clinically guided).
• Sepsis leading to DIC.
• Endocrine disorders: TSH, Free T4.

7. Review imaging for cirrhosis/splenomegaly. If inconclusive, obtain abdominal ultrasound.

8. Consider mechanical causes: Dialysis/ECMO/IABP/cardiopulmonary bypass/artificial heart valve?

9. Evaluate pregnancy-related disorders: HELLP, AFLP, gestational thrombocytopenia.

10. Assess for autoimmune conditions if clinically warranted. Consider SLE and other rheumatological diseases.

11. Consider rare but serious differentials:
• CAPS, other TMA causes, PNH
• Post-transfusion purpura, HLH
• Pursue only with appropriate clinical suspicion

12. If no clear etiology identified, consider ITP as diagnosis of exclusion.

Key Clinical Considerations:
• Critically ill patients frequently have multifactorial thrombocytopenia [A combination of some of the above].
• Primary HLH presenting de novo in adults is exceedingly rare.
• Thrombocytopenia with thrombosis: Consider DIC, TTP, HIT, PNH, or VITT.

[Image AI Generated]”

Thrombocytopenia

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