Cases/Haematology

Man of 72 with Iron Deficiency Anaemia and No Symptoms — Free SCA Practice Case

Man of 72 with iron deficiency anaemia and no symptoms

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

Frank Whitaker

Age

72 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation. The patient has been asked to book a call to discuss blood tests done at a routine review.

Reason for Encounter

"I got a message to ring about my blood tests. I feel perfectly well, so I'm not sure what the fuss is about."

Medical Records

●PMH: Osteoarthritis. Otherwise well.
●Medications: Paracetamol PRN. No aspirin, NSAIDs, or anticoagulants on repeat.
●Allergies: NKDA.
●Recent results (routine bloods, 1 week ago): Hb 101 g/L (low). MCV 74 fL (low, microcytic). Ferritin 8 µg/L (low). B12, folate normal. U&E, LFTs normal. Conclusion: iron-deficiency anaemia.

Patient Script

For the friend playing the patient role

Character Overview: You are Frank, a 72-year-old retired teacher. You are cheerful and pragmatic, and genuinely puzzled about why you have been called — you feel completely well. You are the sort who "doesn't like a fuss" and will initially be reluctant about the idea of hospital tests when you have no symptoms. You are reasonable and will accept sensible advice once it is explained, though the word "cancer" will worry you.

Opening Sentence: "Hello, Doctor. I got a text asking me to call about my blood tests. I feel absolutely fine, so I can't imagine there's much wrong. What's this all about?"

History if Asked (Data Gathering Phase)

●Symptoms: "Honestly, I feel well. I'm active, I walk the dog, I do my garden. No real tiredness beyond what you'd expect at 72."
●Bowels: "My bowels are... fairly normal. Maybe a touch looser lately, now you ask, but nothing dramatic. No obvious blood that I've noticed."
●Weight: "I might have lost a little weight over a few months. I put it down to being more active in the garden."
●Diet: "I eat reasonably. Bit less red meat than I used to, maybe."
●Bleeding: "No, no blood when I go to the toilet that I've seen, no black stools. No blood in my water."

ICE — Ideas, Concerns, Expectations

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

●Ideas: Frank assumes that because he feels well, the low blood count is probably nothing — perhaps just his diet or old age. "I just assumed it's my age, or not eating enough red meat. If I felt ill I'd understand the fuss."
●Concerns: He has not thought about anything serious, and the idea of a cancer-pathway referral and a colonoscopy when he feels fine is unwelcome and a little frightening. "A camera test? For no symptoms? That does sound alarming when you put it like that. Is this about cancer?"
●Expectations: He expects to be told to take some iron tablets or eat more greens and be sent on his way. "I thought you'd just tell me to take some iron and that'd be that."

If Asked — Medical History and Medications

The patient confirms these details only when directly asked.

●NSAIDs/aspirin/anticoagulants: "No, I don't take aspirin or ibuprofen regularly, no blood thinners. Just paracetamol for my knees now and then."
●Previous anaemia: "Not that I know of. My bloods have always been fine before."
●Family history: "My brother had bowel cancer in his late sixties, actually. He's okay now, caught it early."
●Previous GI problems: "No ulcers, no indigestion to speak of."
●Alcohol: "A couple of glasses of wine at the weekend."

Social History and Lifestyle Impact

Frank is a retired teacher who lives with his wife. He is active and independent.

●Activity: "Very active — walking, gardening, out most days."
●Diet: "Reasonable, though I've cut back on red meat over the years."
●Support: "My wife's well, we look after each other. She'd come with me to any appointments."
●Smoking: "Gave up thirty years ago."

If Asked — GI and Anaemia Red-Flag Screen

The patient answers these only when directly asked.

●If asked about change in bowel habit: "A bit looser over the last couple of months, now you mention it. Nothing I'd have bothered you about."
●If asked about rectal bleeding or blood in stool: "No blood that I've seen."
●If asked about black/tarry stools (melaena): "No, nothing like that."
●If asked about unintentional weight loss: "Maybe a few pounds over a few months. I assumed it was the gardening."
●If asked about abdominal pain or a lump: "No pain, no lump."
●If asked about dysphagia or dyspepsia: "No trouble swallowing, no indigestion."
●If asked about anaemia symptoms (breathlessness, tiredness, dizziness, chest pain): "A bit more puffed on hills lately, maybe. Nothing much. No dizziness or chest pain."
●If asked about urinary blood: "No, nothing in my water."

Responses to Management (The Negotiation Phase)

●If the Doctor explains iron-deficiency anaemia in a man needs investigation for internal bleeding: "But I feel fine. Why do I need all this if there are no symptoms?" (The tested point is explaining that iron-deficiency anaemia in a man is itself a red flag for occult gastrointestinal blood loss and warrants investigation regardless of symptoms.)
●If the Doctor recommends an urgent (2-week-wait) referral for colonoscopy: "A cancer referral? A colonoscopy? That's a big jump from a blood test, isn't it?" (The tested point is explaining the suspected-cancer pathway honestly but without needless alarm.)
●If the Doctor starts iron replacement: "So I do take iron as well? Won't that just fix it and we can forget the tests?"
●If the Doctor asks about the subtle symptoms he minimised: "Well, now you mention the weight and the bowels... I hadn't thought those were connected."
●If the Doctor safety-nets: "What should I look out for in the meantime?"

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

Iron-Deficiency Anaemia — Recognise It

●Iron-deficiency anaemia (IDA) is a microcytic anaemia (low MCV) with a low ferritin (the most useful confirmatory test, though ferritin can be falsely raised by inflammation).
●Establishing that an anaemia is iron-deficient is the trigger for investigating the cause.

IDA in Men and Postmenopausal Women Is a Red Flag

●In men of any age and postmenopausal women, IDA is presumed to be due to gastrointestinal blood loss until proven otherwise — including colorectal and upper-GI cancer — and requires investigation regardless of symptoms.
●Feeling well does not exclude a serious cause: GI cancers can bleed slowly and silently, producing anaemia before overt symptoms.

The NICE NG12 Pathway

●NICE NG12 recommends urgent suspected-cancer (2-week-wait) referral for adults with iron-deficiency anaemia in this context (men; postmenopausal women).
●Investigation typically includes colonoscopy and, to identify the source, upper GI endoscopy; coeliac serology is checked as a cause of malabsorptive iron deficiency.

Iron Replacement — Alongside, Not Instead of, Investigation

●Start oral iron (e.g. ferrous sulfate/fumarate) to correct the anaemia; alternate-day dosing improves tolerability and absorption. Take with vitamin C/orange juice to aid absorption; manage constipation.
●Iron replacement treats the anaemia but does not remove the need to find the cause — never let it substitute for investigation.

The Wider Differential of Iron Deficiency

●Consider reduced intake (diet), malabsorption (coeliac disease, gastric surgery), drug-related blood loss (NSAIDs, aspirin, anticoagulants), and urinary or other blood loss — while prioritising exclusion of GI malignancy in the at-risk groups.

Communicating a Suspected-Cancer Referral to a Well Patient

●Explaining why a symptomless blood result needs urgent, sometimes invasive, investigation is a core skill. Be honest that referral is to exclude serious causes, proportionate (most people referred do not have cancer), and supportive — securing engagement so the patient attends.

Safety-Netting and Follow-Up

●Safety-net for significant rectal bleeding, melaena, worsening breathlessness, chest pain, or collapse, and track the referral and results so the pathway is not lost.

Common Candidate Mistakes in This Case

●Treating the anaemia as dietary/benign: prescribing iron and reassuring, without investigating occult GI bleeding — the key error.
●Not referring urgently: failing to use the NG12 2-week-wait pathway for IDA in a man.
●Being reassured by "no symptoms": colluding with the patient's belief that feeling well excludes serious disease.
●Omitting coeliac testing or the wider work-up: narrowing the differential prematurely.
●Poor communication: either alarming him into distress or under-selling the referral so he declines it.

Free MRCGP SCA practice case for GP registrars covering Man of 72 with Iron Deficiency Anaemia and No Symptoms — 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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