Cases/Haematology

Low Platelet Count On Routine Bloods — Free SCA Practice Case

Young adult with a low platelet count on routine bloods

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Daniel Okafor

Age

38 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation. The patient was seen in out-of-hours care for bruising and fatigue; a repeat blood test has now been done and he has booked a call to discuss the results.

Reason for Encounter

"I'd like to go through my blood test results, please. I've had bruising coming up for no reason and I've been exhausted."

Medical Records

●PMH: Nil recorded.
●Medications: None. No NSAIDs or anticoagulants.
●Allergies: NKDA.
●Recent notes (out-of-hours, 8 days ago): Spontaneous bruising and fatigue; bruising on both forearms/hands; abdomen soft, non-tender, no masses; observations normal. Urgent FBC requested. U&E, CRP, LFTs, bone profile normal. Platelets 90 × 10⁹/L, other parameters normal. Advised repeat FBC with own GP in 1 week.
●Repeat FBC (yesterday): Hb 140 g/L (normal), WBC 5.5 (normal), neutrophils and lymphocytes normal, platelets 86 × 10⁹/L, MCV 82 (normal). Conclusion: isolated thrombocytopenia.

Patient Script

For the friend playing the patient role

Character Overview: You are Daniel, a 38-year-old cloud engineer. You are articulate and quite frightened. Your older sister had similar symptoms years ago, was diagnosed with leukaemia, and died — so the bruising and the low blood result have you convinced you have leukaemia too. You are holding it together but the fear is close to the surface. You want the results explained honestly and you need reassurance, but you will not be fobbed off.

Opening Sentence: "Hi Doctor. I wanted to go through my blood results. I've had these bruises appearing on my arms and hands for no reason, and I've been shattered. The out-of-hours doctor said something in my blood that helps clotting was low. I have to be honest — I'm terrified it's leukaemia, because that's how it started for my sister."

History if Asked (Data Gathering Phase)

●The bruising: "Bruises coming up on my forearms and the backs of my hands without me knocking them. Started about five weeks ago. It's new — never happened before."
●Fatigue: "Really tired for about five weeks too. Not myself."
●Recent illness (only if asked): "I had a bad sore throat about seven weeks ago — proper flu-ish for a few days — but it cleared up on its own."
●Other bleeding: "No nosebleeds or bleeding gums that I've noticed. Nothing when I go to the toilet."
●The fear: "My sister had bruising and tiredness and it turned out to be leukaemia. She died. I can't stop thinking about it."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores his perspective.

●Ideas: Daniel is convinced this is leukaemia, because it mirrors his sister's presentation. "In my mind this is leukaemia. The bruising, the tiredness — it's exactly how my sister started."
●Concerns: His overwhelming concern is a leukaemia diagnosis and dying as his sister did. "I'm frightened I'm going to be told the same thing my sister was, and that I'll leave my kids without a dad."
●Expectations: He wants the results explained clearly and honestly, and to know what happens next. "I need you to be straight with me about what this means and what we do now."

If Asked — Medical History and Medications

The patient confirms these details only when directly asked.

●Medications: "Nothing regular. I don't take ibuprofen or aspirin, no blood thinners."
●Recent infections: "Just that sore throat seven weeks ago."
●Vaccinations/travel: "No recent travel. Vaccinations up to date."
●Family history: "My older sister had leukaemia and died. No other blood disorders that I know of."
●Alcohol: "I don't really drink."

Social History and Lifestyle Impact

Daniel is a cloud engineer. He is married with three children.

●Family: "Married, three kids. That's what makes this so frightening — the thought of not being there for them."
●Work: "Desk-based tech job. The tiredness is affecting my concentration."
●Lifestyle: "Non-smoker, barely drink, no drugs."
●Mood: "I'm anxious and not sleeping, honestly — the worry is constant."

If Asked — Bleeding and Systemic Red-Flag Screen

The patient answers these only when directly asked.

●If asked about mucosal bleeding (nosebleeds, gum bleeding): "No nosebleeds, gums seem fine."
●If asked about blood in vomit, stool, or urine: "No, nothing like that."
●If asked about petechiae (tiny red/purple spots) or a rash: "I have noticed some tiny red pinprick spots on my lower legs, actually."
●If asked about weight loss, night sweats, fever, bone pain: "No weight loss, no night sweats, no fevers, no bone pain."
●If asked about abdominal fullness/lumps (splenomegaly): "No, no tummy swelling or lumps that I've felt."
●If asked about severe headache or neurological symptoms: "No headaches, no visual problems."
●If asked about over-the-counter medicines or supplements: "Nothing — no painkillers, no supplements."

Responses to Management (The Negotiation Phase)

●If the Doctor explains he has a low platelet count (thrombocytopenia): "So what does a low platelet count actually mean? Is that the leukaemia?" (The tested point is explaining thrombocytopenia in plain terms and distinguishing it from leukaemia while taking the fear seriously.)
●If the Doctor explains it is likely post-viral ITP: "So it might just be from that sore throat? But how can you be sure it's not leukaemia?" (The tested point is explaining likely immune thrombocytopenia after a viral illness while still arranging tests to exclude sinister causes.)
●If the Doctor arranges a blood film and further tests: "What are these extra tests for? Will they tell us if it's leukaemia?"
●If the Doctor gives bleeding-risk advice: "So what do I need to be careful about with a low count?"
●If the Doctor discusses referral: "Do I need to see a blood specialist? How urgently?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Domain 2: Clinical Management and Medical Complexity

0 / 18 indicators checked+0−0

Positive (0/9)

Negative (0/9)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

Interpreting an Isolated Thrombocytopenia

●Thrombocytopenia is a low platelet count. An isolated thrombocytopenia — low platelets with normal haemoglobin and white cell count — is reassuring against acute leukaemia, which typically causes other cytopenias and abnormal cells on the film.
●Bruising and petechiae (pinprick spots, often on dependent areas) reflect the low platelets.

Immune Thrombocytopenic Purpura (ITP)

●ITP is immune-mediated platelet destruction, commonly triggered by a preceding viral illness (as here, a sore throat weeks earlier). It is a frequent cause of isolated thrombocytopenia in an otherwise-well person and is often self-limiting or manageable.
●It is a diagnosis of exclusion — confirmed after other causes are considered and a blood film is reviewed.

The Differential of Thrombocytopenia

●Consider: ITP (post-viral, autoimmune), drug-induced (NSAIDs and others), viral (including HIV, hepatitis), B12/folate deficiency, liver disease/hypersplenism, and haematological malignancy (leukaemia — usually with other abnormalities).

Investigation

●Arrange an urgent peripheral blood film (to look for blasts/abnormal cells and confirm the count), plus LFTs, clotting, U&E, B12/folate/ferritin, and HIV/hepatitis screening where indicated.
●The blood film is pivotal in distinguishing benign causes from malignancy.

Bleeding-Risk Assessment

●The risk of significant spontaneous bleeding is low with moderate reductions and rises as the count falls (particularly below ~20–30 × 10⁹/L). Assess for mucosal bleeding, wet purpura, and any serious bleeding.
●Advise avoiding trauma, contact sports, and NSAIDs/aspirin, and reporting bleeding.

Referral and Urgency

●Stable, moderate, isolated thrombocytopenia with a reassuring picture can be investigated in primary care first, with haematology referral if the count falls further, is very low, the film is abnormal, there are other cytopenias, or there is bleeding or systemic illness.
●Very low counts, active/serious bleeding, or a systemically unwell patient warrant urgent/same-day referral.

Communicating with a Frightened Patient

●Where a patient fears a specific serious diagnosis (here, leukaemia, driven by family experience), take the fear seriously, be honest, and give proportionate reassurance grounded in the actual findings — explaining what makes the feared diagnosis less likely while confirming it is being checked.

Safety-Netting

●Advise urgent/emergency help for heavy or uncontrolled bleeding, wet purpura, severe headache or neurological symptoms (possible intracranial bleed), or worsening anaemia.

Common Candidate Mistakes in This Case

●Premature reassurance or premature alarm: either declaring "it's not leukaemia" before the blood film, or fixing on leukaemia despite the reassuring isolated picture.
●Not arranging a blood film: failing to request the pivotal investigation.
●Missing the post-viral clue: not asking about the recent sore throat that points to ITP.
●No bleeding-risk advice or safety-netting: leaving a thrombocytopenic patient without precautions or red flags.
●Ignoring the fear: handling the call as a numbers exercise and not addressing the leukaemia fear rooted in his sister's death.

Free MRCGP SCA practice case for GP registrars covering Low Platelet Count On Routine Bloods — Haematology. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

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