Should I refer this patient to a hematologist?

Hematology Referral Decision

You should refer to a hematologist if the patient has unexplained cytopenias, abnormal bleeding or bruising with laboratory abnormalities, platelet count <20 × 10^9/L, suspected hematologic malignancy, or specific high-risk conditions outlined below. 1, 2

Urgent Referral (Within 24-72 Hours)

Refer immediately for:

• Platelet count <20 × 10^9/L in newly diagnosed or established immune thrombocytopenia (ITP), regardless of symptoms 1, 2, 3
• Significant mucosal bleeding (oral, nasal, gastrointestinal, genitourinary) at any platelet count 2, 3
• Suspected hematologic malignancies including acute leukemias, myelodysplastic syndromes, or myeloproliferative neoplasms 1
• Unexplained cytopenias in any cell line (anemia, thrombocytopenia, leukopenia) 1
• Abnormal peripheral blood smear showing immature myeloid cells, blasts, or dysplastic features 1

Standard Referral Indications

Refer for non-urgent evaluation when:

• Corticosteroid-dependent or unresponsive ITP after ≥3 months of treatment 1, 2
• Easy bruising or bleeding problems with abnormal CBC, platelet function studies, or von Willebrand screen 4
• Thrombocytopenia requiring specialized treatment such as thrombopoietin receptor agonists, rituximab, or splenectomy consideration 2
• Suspected inherited platelet disorders or coagulation abnormalities 4, 5
• Multiple myeloma or other plasma cell disorders, particularly with high-risk features 1

High-Risk Populations Requiring Lower Threshold for Referral

Consider earlier referral for:

• Elderly patients (>60 years) with thrombocytopenia due to higher bleeding risk 1, 2, 3
• Patients on anticoagulants or antiplatelet medications with any degree of thrombocytopenia 1, 2, 3
• Patients requiring surgery who have not been screened for bleeding disorders 4
• Patients with limited access to care or social concerns affecting follow-up 2, 3

When Outpatient Management Without Immediate Referral Is Acceptable

You may observe without urgent referral if:

• Platelet count ≥30 × 10^9/L in asymptomatic patients without bleeding 3
• Mild thrombocytopenia (>100 × 10^9/L) without bleeding symptoms, risk factors, or upcoming procedures 3
• No active bleeding and no concerning laboratory findings on CBC and peripheral smear 3

However, even in these cases, ensure follow-up within 24-72 hours if any hematologic abnormality is identified and provide clear patient education about warning signs requiring emergency care 2, 3

Critical Pitfalls to Avoid

• Failing to arrange timely follow-up within 24-72 hours for patients with platelet counts <20 × 10^9/L managed as outpatients 1, 2
• Not screening before surgery in patients with history of easy bruising or bleeding 4
• Dismissing mild cytopenias without peripheral smear review, as these may represent early hematologic malignancy 1
• Inadequate patient education about bleeding warning signs when managing outpatient 2, 3

Specific Screening Recommendations

Before referring, obtain:

• Complete blood count with differential and platelet count 4, 1
• Peripheral blood smear review 1
• If bleeding history present: platelet function studies and von Willebrand screen 4

Refer to hematology for interpretation if any of these tests are abnormal 4, 1