Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
主诉 (zhǔ訴) Chief Complaint:
This section will vary depending on the severity of ITP. Common complaints may include:
Easy bruising or bleeding (most common)
Petechiae (small red spots on the skin)
Nosebleeds or gum bleeding (less common)
Heavy menstrual bleeding (in women)
Fatigue (less common)
现病史 (xiàn bìng shǐ) History of Present Illness:
Age at onset of symptoms
Duration and severity of bleeding symptoms
History of any recent infections, vaccinations, or medications (potential triggers)
Blood transfusions (if any)
既往史 (jì wàng shǐ) Past Medical History:
Underlying medical conditions (e.g., autoimmune diseases, HIV/AIDS, hepatitis C)
Prior surgeries or procedures (especially splenectomy)
History of blood clots (may indicate a different diagnosis)
家族史 (jiā zú shǐ) Family History:
Family history of ITP (uncommon)
Family history of autoimmune diseases (may increase risk)
社会史 (shè huì shǐ) Social History:
Current medications and supplements (potential triggers)
Recent travel history (potential exposure to infections)
Alcohol or drug use (may worsen platelet function)
查体 (chá tǐ) Physical Examination:
Vital signs (normal in most cases)
Skin and mucous membranes:
Look for signs of bleeding (petechiae, purpura)
Lymph node examination (may be enlarged in some cases)
Spleen size assessment (splenomegaly uncommon in ITP)
辅助检查 (fú zhu zhuān chá) Laboratory Tests:
Complete blood count (CBC):
Low platelet count (thrombocytopenia) is the hallmark finding.
May also show mild anemia (if bleeding has been significant).
Peripheral blood smear:
May reveal abnormal platelet appearance (important for diagnosis).
Reticulocyte count:
May be elevated if the bone marrow is producing new red blood cells to compensate for blood loss.
Coagulation tests (PT, PTT):
Typically normal in ITP (helps differentiate from other bleeding disorders).
Additional tests may be done depending on suspected underlying causes (e.g., autoimmune antibodies).
影像学检查 (yǐng xiàng xué jiǎn chá) Imaging Studies:
Imaging studies are not routinely needed for ITP diagnosis.
Ultrasound of the spleen (uncommon) – may be used to assess for splenomegaly in specific situations.
诊断 (zhěn duàn) Diagnosis:
Immune thrombocytopenia (ITP):
Based on clinical presentation (bleeding symptoms), low platelet count on CBC, and exclusion of other causes of thrombocytopenia.
Specify the type of ITP:
Primary ITP (no identifiable cause)
Secondary ITP (associated with another underlying condition)
分期 (fēn qī) Classification (optional):
Some classification systems categorize ITP based on the duration of symptoms (acute, chronic).
治疗方案 (zhì liáo fāng àn) Treatment Plan:
Treatment approach depends on the severity of bleeding, platelet count, and overall health.
Observation: May be appropriate for mild ITP with minimal bleeding.
First-line treatment options:
Corticosteroids (prednisone) – to suppress the immune system and increase platelet production.
Intravenous immune globulin (IVIG) – to temporarily boost platelet levels.
Second-line treatment options (if first-line fails):
Splenectomy (surgical removal of the spleen) – effective but has potential complications.
Rituximab (B-cell depleting therapy) – for certain cases.
Thrombopoietin receptor agonists (TPO-RAs) – medications that stimulate platelet production.
预后 (yù hòu) Prognosis:
Discuss the outlook based on the type of ITP, severity of bleeding, and response to treatment.
ITP can be acute (resolves on its own) or chronic (long-term).
Most patients with ITP achieve good control with treatment.
健康指导 (jiàn kāng zhǐ dào) Patient Education:
Importance of avoiding activities that increase bleeding risk (contact sports