Cases/Haematology

Bruises, Tiny Red Spots and A Heavy Period — Free SCA Practice Case

Young woman with bruises, tiny red spots and a heavy period

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

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Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Tamara Boateng

Age

23 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation. The laboratory phoned the practice this morning about yesterday's blood test.

Reason for Encounter

"The receptionist said something in my blood test was low."

Medical Records

●PMH: Nil. Medications: None. Allergies: NKDA. Contraception: Condoms.
●Social: Graphic designer, non smoker.
●10 days ago (nurse): Tired for two months, periods heavier for three. BP 108/66, pulse 78. FBC and ferritin requested.
●Results (yesterday): Platelets 18 (150 to 400), Hb 112 (115 to 165), MCV 79, WCC 6.4, ferritin 8. Laboratory comment: no platelet clumps seen. FBC two years ago: Hb 131, MCV 88, platelets 262.

Patient Script

For the friend playing the patient role

Character Overview: You are Tamara Boateng, a 23 year old junior graphic designer. You are organised, quick talking and used to sorting everyone out. You share a rented house with two housemates and have no car. Your mum Adwoa lives an hour away. It is Thursday, about half past eleven, and you are taking this call in a spare meeting room at work. You captain your netball team and the league final is on Saturday. You are also midway through a client pitch, with the deck due with your manager by the end of today. You have been exhausted for about two months and your periods have been heavier for about three, so you asked the nurse to check your iron before the final. You think this is a heavy period and low iron, you put the bruises down to the knocks you take at netball and the red dots on your ankles down to new socks, and you want iron tablets so you are fit to play on Saturday. You start cheerful and brisk. Underneath you are anxious, and you hate needles: you nearly fainted when the blood was taken yesterday. You push back first but will agree to a clearly explained plan. You never guess a medical name.

Opening Sentence: "Hi doctor, thanks for ringing. The receptionist said something in my blood test was low. I'm hoping it's just iron, because my periods have been really heavy and I've been wiped out. The thing is, I captain my netball team and we've got the league final on Saturday, so I'm hoping you can sort me out with some iron tablets today."

History if Asked (Data Gathering Phase)

●Why the blood test was done (if asked): "I've been shattered for about two months and my periods have got heavier over the last three. I asked the nurse to check my iron before the final."
●Bruising (if asked about bruises or her skin): "Six or seven on my shins and thighs, one on my left thigh the size of my hand, one on my forearm. I play netball and you get bumped and land hard, so I put it down to that, but I couldn't tell you how I got some of them. I noticed them about ten days ago."
●Red spots (if asked about spots or a rash): "Tiny red dots on both ankles and feet since Monday."
●Gums and nose (if asked about bleeding from the mouth or nose): "My gums have bled when I brush my teeth for about a week. I had a nosebleed on Tuesday evening that lasted about ten minutes."
●Other bleeding (if asked about blood blisters in the mouth, urine, stools, vomit or past bleeding): "No blisters. My wee and poo are normal, nothing's black, and I haven't been sick. I've never bled before. My wisdom teeth came out at 19 with no problem."
●The period now (if asked how heavy it is): "It started on Monday and got really heavy on Tuesday. I'm changing a super pad every hour or hour and a half, I changed twice in the night, and there are clots the size of a 50p. This morning it came through onto my trousers."
●Usual periods and pregnancy (if asked): "Normally every 28 days, five days of bleeding, a pad every three or four hours at worst. For about three months they've been heavier. I can't be pregnant. I came on Monday and we use condoms."
●Light headed and breathless (if asked about dizziness or how she is in herself): "Now you say it, I got light headed standing up in the shower this morning, and again at my desk. I get puffed on the stairs, with a racing heart, but not at rest."
●Painkillers and other medicines (if asked what she takes for the period, or about aspirin, supplements or the pill): "Ibuprofen, two of the 200 milligram ones, three times a day since Monday, and the same last month. It's the only thing that touches the cramps. Paracetamol does nothing for me. No aspirin, no regular tablets, no supplements and nothing new."
●Neurological and general screen (if asked about headache, confusion, vision, speech, weakness, fever, sweats, weight, lumps, bone pain, joints, ulcers, yellow skin, dark urine or bloody diarrhoea): "No headaches. My vision's fine, I'm thinking straight and I've no weakness. No temperature or sweats, my weight's steady, no lumps, bone or joint pain or ulcers. Nobody's said I look yellow."
●Recent illness, alcohol and drugs (if asked): "A stomach bug three weeks ago, two days of being sick and diarrhoea, no blood. About four glasses of wine at the weekend. I don't smoke or take drugs."
●Family and sexual health (if asked about bleeding in the family or partners): "Nobody in the family bleeds easily. One boyfriend for a year, we both had a sexual health check a few months ago and it was clear. No tattoos or injecting."
●Past health (if asked): "I've never been ill. No transfusions. No allergies. I came off the pill two years ago."

Ideas, Concerns, Expectations

Gating note: Tamara does not raise any of the following unless the doctor asks what she thinks is going on, what is worrying her, or what she was hoping for. The deeper worry and the fear of needles come out only if the doctor asks more than once or asks what worries her most.

●Ideas: "I thought it was just my period. The bruises are from netball, and the red dots are my new socks."
●Concerns: "I don't want anything to wreck the final. I'm the captain, and the team is relying on me." Pressed further: "And if my blood's bad enough that the surgery's chasing me the same day, is it something really serious? I don't want to be told it's something awful. And I hate needles. I nearly passed out yesterday."
●Expectations: "Some iron tablets, and something to calm my period down. My mum had those tablets once that stop heavy periods, tranexamic something, and they worked really well. And for you to tell me it's fine to play on Saturday."

Social History and Lifestyle Impact

●Work and family: "I'm halfway through a pitch for a big client and the deck is due with my manager by the end of today. I don't want to walk out and leave it half done. I haven't told Mum, I don't want her worrying." Reluctant to leave at first. Once the doctor explains why it cannot wait, or offers to help, she agrees to tell her manager, who is reasonable and would cover the deck.
●Getting there (if asked how she could get there or who could help): "Jasmine finishes work at one and she's got a car, she'd take me like a shot. Nobody else is free. I could get a taxi."
●Exercise (if asked): "Netball training on Tuesdays and a match on Saturdays. I played last Saturday but I skipped training this Tuesday because I was so tired. Officially it's non contact, but I get shoulder barged and I've gone over a few times."

Responses to Management (The Negotiation Phase)

●
If the doctor explains that her platelets are very low, or gives the likely cause:
- ●Reaction: Taken aback. "Platelets? I thought it'd be iron. So that's why I've been bruising?" If a cause or tests are mentioned: "Is it dangerous? Is it for life? Did I cause it, with netball?" An honest answer steadies her.
●
If the doctor says she must be assessed or speak to a haematologist today:
- ●Reaction: Resists at first. "Today? I'm in the middle of a pitch at work. Can't I just have the tablets and get it rechecked later?" Once told the count is low enough, and she is bleeding enough, that it cannot wait: "Okay. I didn't realise it was that bad. Do I just turn up?" Reassured if the doctor phones ahead.
●
If the doctor says she should not play on Saturday or should avoid sport:
- ●Reaction: Upset. "I can't not play. I'm the captain, it's the final." Once the doctor acknowledges what the team means to her and explains why a knock to the head or belly could cause serious bleeding: "Okay. I'd never forgive myself if I got hit and ended up in hospital anyway. Can I at least go and watch, and tell the team?" She asks "Could I play a bit if I feel all right?" but accepts a clear no. If instead the doctor says she can play, offers only iron tablets, or suggests a recheck after the final, she is relieved: "Great, so I can still captain them," and does not raise the bruises again.
●
If the doctor tells her to stop ibuprofen, or declines her mum's tablets:
- ●Reaction: Puzzled. "But it's the only thing that helps the cramps." Told it makes bleeding worse: "Oh, I didn't know that. What can I take instead?" About her mum's tablets: "Why can't you just give me those?" She accepts that the hospital team will decide.
●
If the doctor mentions blood tests, asks how she will get there, or suggests an ambulance:
- ●Reaction: "Do I have to have needles again? I nearly fainted yesterday." Reassured if told she can tell the staff and lie down. On getting there: "Jasmine finishes at one. Could I wait till then? Or I could get a taxi." Told to go soon and not to drive or take the bus alone while light headed: "Okay. I'll ring Jasmine now and tell my manager I have to go." She accepts an ambulance if nobody can take her.
●
If the doctor gives safety netting or checks her understanding:
- ●Reaction: Given vague advice such as "come back if it gets worse": "It's already really heavy though. What counts as bad enough to ring 999?" Asked to examine herself on the call, she declines and asks to be seen properly. If the plan is clear she repeats it back accurately, including who is taking her and what means 999. If it is vague: "Sorry, can you go over what I'm actually meant to do?"

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 / 26 indicators checked+0−0

Positive (0/13)

Negative (0/13)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Tamara wants iron tablets and a green light to captain her team in Saturday's final. The result says otherwise: a platelet count of 18 in a young woman already bleeding from skin, gums, nose and womb. The skill is to hold the line on same day action while acknowledging the final and a pitch she is midway through.
●Model plan: recognise that this cannot wait; speak to the on call haematology team today (or send her directly to the emergency department or an acute assessment unit) with a full handover; stop ibuprofen and offer paracetamol; advise against netball and high impact exercise; arrange a safe way to get there; give specific 999 advice; and agree who confirms the outcome.
●Also acceptable: seeing her at the practice first, provided the hospital or haematology step still follows the same day. Not acceptable: a repeat count in days, a routine referral, or "go to A&E if it gets worse".

Reading the Result and Why It Cannot Wait

●Thrombocytopenia is a count below 150 × 10⁹/L (CKS, Platelets: abnormal counts and cancer, revised December 2025). Her white cells are normal and her haemoglobin only slightly low, with low MCV and ferritin from heavy periods. This is an isolated low platelet count, not a fall in all cell lines, which would make leukaemia likelier.
●Low platelets cause bleeding from skin and mucous membranes: bruises, petechiae, gums, nose and heavy periods. A normal count two years ago with no clumps makes a false low unlikely.
●Risk rises below about 20 and counts below 10 carry a high risk of serious spontaneous bleeding. CKS advises emergency admission, meaning same day assessment or urgent specialist advice, for active bleeding or a count below 20. Below 50 it asks for urgent haematology referral.
●The international consensus report (Provan 2019) notes that treatment can usually be given as an outpatient unless there is active bleeding or it is the first presentation with a count of 20 or below. Tamara is both.

Differential Diagnosis

●Immune thrombocytopenia (ITP) is the commonest cause of an isolated very low count in a well young adult, and is a diagnosis of exclusion. It can be primary or secondary to infection (HIV, hepatitis C), autoimmune disease such as lupus, or drugs.
●Thrombotic thrombocytopenic purpura (TTP) and related thrombotic microangiopathies are rare emergencies: low platelets, red cell fragments on the film, neurological symptoms, fever, kidney injury or bloody diarrhoea. They need immediate specialist treatment, which is why the neurological and gut screen matters even when ITP is likelier.
●Others: drugs (anti inflammatories, quinine, heparin, penicillins), alcohol, B12 or folate deficiency, liver disease, leukaemia, DIC, pregnancy related causes such as HELLP, and inherited causes. A recent stomach bug and the ibuprofen are plausible contributors but do not change the plan.

The History That Matters

●Where she bleeds (skin, gums, nose, womb, urine, stools), since when and whether it is worsening. Blood blisters in the mouth and nosebleeds that are hard to stop point to higher risk.
●How heavy the period is: pads per hour, clots larger than a 50p coin, flooding, light headedness.
●Every drug, including over the counter anti inflammatories. She has taken 1.2 g of ibuprofen daily for three days, which impairs platelet function. CKS advises avoiding anti inflammatory and antiplatelet drugs in thrombocytopenia.
●Red flags for a dangerous cause: headache, confusion, speech, vision or weakness change, fever, jaundice, dark urine, bloody diarrhoea, weight loss, bone pain, lumps, joint pain and rash.
●Recent illness, pregnancy possibility, alcohol, blood borne virus risk and family history of bleeding.

Managing the Call: Drugs and Handover

●Make the call yourself rather than leaving it to her. Give the team platelets 18, Hb 112, MCV 79, ferritin 8, normal white cells, a normal count two years ago, the bleeding sites, the heavy period, the ibuprofen, no neurological symptoms and that she plays netball, and say who is bringing her and when.
●Stop ibuprofen and avoid other anti inflammatories and aspirin. Offer paracetamol. Advise care to avoid knocks and cuts, and gentle tooth brushing, until she is reviewed.
●Do not settle this as heavy menstrual bleeding with tablets at home. Tranexamic acid and hormonal measures are supportive options in severe thrombocytopenia (Provan 2019), reasonable alongside same day assessment, but haematology should direct them. The BNF lists thromboembolic disease as a contraindication to tranexamic acid.
●Oral corticosteroids are first line for ITP that needs treatment, but a blood film must be reviewed before anyone with suspected ITP goes home (South East London guideline, 2020). The error is starting steroids at home instead of arranging assessment; a dose on haematology advice is fine.
●Consider a pregnancy test (CKS).

What the Hospital Will Do

●Repeat count with film, clotting screen, kidney and liver tests, B12, folate, iron studies, and HIV and hepatitis B and C screening, then an autoimmune screen as the history suggests.
●If ITP is confirmed and treatment is needed, first line is a short corticosteroid course, such as prednisolone around 1 mg/kg daily for about 2 weeks then tapered, or dexamethasone 40 mg daily for 4 days given for 1 to 3 cycles (Provan 2019).
●About 30% of adults remit within 12 months, so honest answers to "is it for life" promise neither way.

Netball, Contact Sport and High Impact Exercise

●CKS (Platelets: abnormal counts and cancer) advises general measures to reduce bleeding risk, including avoiding antiplatelet drugs, NSAIDs and trauma. The ITP Support Association leaflet on choosing a sport (2017) says the greatest risk at a low count is serious head or internal injury, so contact sports and activities with a risk of falling are not advisable. It lists netball as a sport with a risk of being hit or bruised, and advises people with a count under 20 and active bleeding to choose sports where they are unlikely to be hit or fall.
●Tamara's count is 18 with active bleeding and no diagnosis. Netball is officially non contact, but she is shoulder barged and goes over on court. She should not play on Saturday or train, and should avoid other high impact exercise, until haematology have reviewed her.
●Return to sport is a haematology decision once the count is safe and the cause is clear. Sources vary on thresholds, so do not quote a count or promise she will play again soon. Acknowledge what captaining the team means, and offer a fit note or letter for work and help telling her team and manager.

Safety Netting and Follow Up

●She should not drive or go alone on public transport while light headed. Ring 999 for fainting or collapse; bleeding that is heavier or will not settle; a nosebleed not stopped after 10 to 15 minutes of firm pressure; blood blisters in the mouth; vomiting blood, black stools or blood in the urine; and any sudden severe headache, confusion, drowsiness, vomiting, or speech, vision or weakness problem, or head injury, because intracranial bleeding is the rare but most serious complication.
●"Come back if it gets worse" means little when she is already bleeding heavily. Tie each sign to an action.
●The practice should learn the outcome the same day or next morning.
●Her ferritin of 8 and Hb of 112 show iron deficiency from months of heavy periods that began before the count fell. Oral iron such as ferrous sulfate 200 mg once daily corrects it, continued for 3 months after correction (CKS Anaemia, iron deficiency, revised July 2026). Heavy menstrual bleeding is then reviewed under NICE NG88. Both are later steps.

Common Candidate Mistakes in This Station

●Treating it as iron deficiency and a heavy period, starting tranexamic acid, mefenamic acid or iron and booking a routine review, so the count of 18 is never acted on.
●Offering a repeat test in days, a routine referral, or "go to A&E if it gets worse" instead of arranging same day assessment.
●Agreeing that she can play on Saturday, or leaving sport unaddressed because she is persuasive and the final matters to her.
●Missing the ibuprofen, or recommending naproxen or mefenamic acid.
●Starting oral steroids at home instead of arranging assessment, or giving ITP or leukaemia as certain before the film and tests.
●Not asking about headache, confusion, fever and the wider screen, so TTP is missed.
●Telling her to drive herself, or giving 999 symptoms with no safe way of getting in.
●Pressing on without acknowledging what captaining the final means to her, or ignoring the client pitch that makes her reluctant to leave work.

Mapped to the RCGP curriculum topic: Haematology.

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