Risk for thrombocytopenia assessment

lhoot

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Good Morning,
I’m hoping to get some advice on a particular scenario. Patient is having surgery in the near future. Patient is sent to a separate physician for assessment of his chronic thrombocytopenia. The thrombocytopenia is a new condition to the assessing physician, but not a new diagnosis for the patient. Old platelet counts are reviewed and new labs ordered. No current bleeding issues are noted. Patient has had issues in the past with excessive bleeding with prior surgeries. Patient is to return to physician for risk of surgery assessment when labs are back.

My question is, what would the risk be for this encounter? The physician doesn’t state the stability of the thrombocytopenia. Since, he’s waiting for new labs to make his assessment, would this count as an “undiagnosed new problem with uncertain prognosis” or “one stable chronic illness”? The nature of the presenting problem is the only relevant piece of information available for calculating the risk for this visit.

Thank you,
Laura
 
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