Woman of 68 with Iron Deficiency Anaemia Who Only Wants Iron Tablets — Free SCA Practice Case
Woman of 68 with iron deficiency anaemia who only wants iron tablets
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 MinuteFive cases are free: a live 12-minute consultation with an AI patient each, marked, and no card.
Materials for Candidate
Please review before starting the consultation
Patient Profile
Full Name
Parveen Akhtar
Age
68 years
Consultation Type
TelephoneAge
68
Situation
Telephone Consultation.
Reason for Encounter
"Blood results. Asks whether you could just prescribe iron tablets, as she cannot easily attend appointments."
Medical Records
- ●PMH: Hypertension. Hypothyroidism. Iron deficiency anaemia in pregnancy. Menopause 50.
- ●Medications: Amlodipine 5 mg, levothyroxine 75 micrograms.
- ●Allergies: NKDA.
- ●Social: Widowed. Never smoked.
- ●Screening: Bowel screening kit normal 18 months ago.
Recent Results (9 days ago)
- ●Blood tests: Hb 94 g/L (131 two years ago), MCV 76 fL, ferritin 6 micrograms/L. White cells, platelets, B12, folate, TSH, U&E, LFTs and CRP normal. NT proBNP 168 ng/L.
- ●Nurse review: BP 134/78, pulse 84 regular.
Patient Script
For the friend playing the patient role
Character Overview: You are Parveen Akhtar, a 68 year old retired dressmaker. For thirty years you ran an alterations business from your front room, but you have taken in no sewing for months because you are too tired. Your husband Rafiq died four years ago. You live alone in a terraced house with steep stairs and the only bathroom upstairs.
Your daughter Saima, 36, lives five minutes away. She separated from her husband last year and six weeks ago started a shift job as a train conductor, on probation for the next three months. You look after her daughter Inaya, 2, all day Monday to Friday, and walk her son Zayn, 7, to school and back. Your son Adil lives in Sheffield and works from home Mondays and Fridays. You are on the call at home while Inaya naps.
For three months you have been puffed on the stairs and shattered by the afternoon, and for ten weeks your motions have been looser and more frequent, which you put down to a bug from Zayn. You are sure it is your iron again, as in all four pregnancies, and you want tablets. You have not told Saima about the breathlessness or the blood test.
You are warm, chatty and proud of coping, and you hate being a burden. When tests are mentioned you push back, because you cannot see how to do hospital appointments with Inaya, and you would rather wait until Saima has finished her probation. Underneath, you are frightened a test will find something serious and that Saima will lose her job. You say this only if the doctor explores your worries, and you never say cancer unless the doctor does first; you say "something nasty". An honest explanation that takes the children seriously, a test you can do at home and help planning around Inaya will bring you round. If the doctor is dismissive or vague, you say you will think about it and steer back to the tablets.
Opening Sentence: "Hello, doctor, it's Parveen Akhtar. They said you wanted to talk about my blood test. I'm guessing it's my iron again? If you could just put some tablets on a prescription, that'd be lovely, because I've got my granddaughter all day and I can't really be coming in."
History if Asked (Data Gathering Phase)
- ●Breathlessness: "It's the stairs, mostly. I have to stop halfway and get my breath. Carrying Inaya up for her nap I'm puffing like an old train. It's been creeping up over about three months." Not at rest or at night, one pillow.
- ●Tiredness: "I'm shattered by the afternoon. When Inaya naps, I nap, which isn't like me."
- ●Bowels, when first asked: "Well, my tummy's not been right, if I'm honest. Ten weeks or so. I thought Zayn had brought a bug home." Details: "I used to go once, first thing. Now it's two or three times a day, softer, sometimes a bit runny, and I have to rush." Never at night. No one else had a bug: "Actually, no. The children were fine."
- ●Blood, black stools and pain: "I haven't seen any blood, but honestly I don't really look, with Inaya banging on the door." Colour normal as far as she has noticed. A bit of rumbling and wind, no real pain. Appetite and weight unchanged.
- ●Previous anaemia and tests: "I was always low on iron when I was carrying my children. The tablets sorted me out every time." Bowel screening: "I did that poo test they post you, about a year and a half ago. It came back fine." Never had a camera test.
Ideas, Concerns, Expectations
Gating note: Parveen raises none of this herself. Each part comes out only when the doctor asks what she thinks is going on, what is worrying her, or what she was hoping for. The deeper worry comes out only if the doctor explores further.
- ●Ideas: She is sure it is her iron again and that the loose motions are a bug. If asked: "It's my iron, isn't it? Same as when I was having my babies. A few weeks of tablets and I'll be right as rain."
- ●Concerns, first answer: Practical. "I can't be doing hospital appointments, doctor. Saima's only just started this job, she's on probation for another three months, and there's nobody else to have Inaya."
- ●Concerns, if the doctor explores further: Her voice goes quieter. "I'm not daft. I know why they send people my age for camera tests. And if they find something, I'm out of action, Saima loses her job, and those children have had enough upset this year."
- ●The test itself (if asked, or if the doctor picks up her remark about her neighbour): "My neighbour Bernie had one of those cameras. She said the drink the day before was the worst bit, on the toilet all night. And I'd be so embarrassed." If asked more: "I'd much rather a lady did it."
- ●Expectations: Tablets today. "If I do need tests, can't we leave it till Saima's probation's finished?"
Medical History, Social History and Associated Symptoms
Gating note: Parveen answers each of these plainly when asked, and mentions the family and home details naturally, not as a speech.
- ●Medicines: Amlodipine in the morning. Levothyroxine "first thing at six with a glass of water, before my cup of tea". No painkillers, aspirin or remedies. No allergies.
- ●Other history: No operations, four normal deliveries. No bleeding since her periods stopped at fifty. No blood in the urine. Never given blood. No bowel trouble in the family.
- ●Home and family: Saima drops Inaya off at seven every weekday. Parveen does the school run morning and afternoon. "Saima's had a horrible year with the divorce. This job's a fresh start for her. I'm not going to be the one who messes it up." She has not told her about the breathing or the blood test: "She's got enough on her plate." Adil in Sheffield is "always saying he wants to help more, bless him".
- ●Diet and habits: "I cook properly, dal, saag, chapatis every day. I drink a lot of tea, mind, with every meal." Never smoked, never drunk. "I'm frightened I'll get puffed carrying Inaya up the stairs and come over funny with her in my arms."
- ●Associated symptoms: Her heart goes a bit fast at the top of the stairs, then settles. Actually yes, the corners of her mouth have been cracked and sore. Everything else is negative: chest pain, fainting, ankle swelling, cough, fever, bloating, heartburn, swallowing problems, vomiting.
Responses to Management (The Negotiation Phase)
- ●If the doctor says she will get the iron tablets, or explains that the result needs looking into and not just treating:
- ●Reaction: Pleased about the tablets: "Lovely, that's all I wanted." When told it needs looking into: "But I've had this before, when I was expecting. The tablets sorted it. Why's it any different now?" If told that without periods or a pregnancy the iron must be going somewhere, most likely the gut: "I hadn't thought of it like that."
- ●If the doctor suggests a home poo test, a coeliac blood test or a urine sample:
- ●Reaction: "I did one of those last year and it was fine. Why do I need another?" If told this test looks for much smaller amounts of blood and things can change in eighteen months: "Oh, so it's not the same one? Well, I can do that at home, at least." On coeliac: "Should I stop the bread till the test?" If told to keep eating it: "Good, because I'm not giving up my chapatis."
- ●If the doctor recommends a referral for camera tests:
- ●Reaction: Resistant. "I can't, doctor, not now. Can't I just take the tablets and do all that once Saima's off her probation? And from what my neighbour told me, it's not a nice test anyway." If told why waiting is a bad idea: "How quick are we talking?" If told within a few weeks: "That quick? So you do think it's something bad." If the doctor names cancer: "I knew that's what you were thinking. Do you think that's what it is?" If told honestly that it is possible but most people sent for these tests do not have cancer: "Right. I'd rather know than lie awake wondering, I suppose." If told it is almost certainly nothing: "Well, if it's probably nothing, why can't it wait?" If told she needs hospital tests even if the poo test is clear: "Then what's the point?" She accepts once told the result decides how quickly she is seen.
- ●If the doctor explores who could help, how the test works or whether Saima knows:
- ●Reaction: About Saima: "She's got enough on. She'd only worry." If the doctor explores this gently: "She'd go mad if she found out I'd kept it from her. I'll tell her tonight." "Adil could come up for a day if he had a bit of notice," and could drive her home after the test. After sedation, "Adil could stop over, then." If offered a female doctor or nurse: "Can I? That would make it a lot easier." If told it cannot be promised: "Well, I'll ask, anyway." If asked to come in she will bring Inaya, and she declines to feel her own tummy over the phone.
- ●If the doctor explains how to take the iron and what to expect:
- ●Reaction: "I have my thyroid one at six." If told to keep them four hours apart: "I'll do it before my lunch." About dark stools: "Black? How am I supposed to know if it's the tablets or something wrong?" About storage: "I'll put them in the top cupboard."
- ●If the doctor gives vague safety netting, or does not say whether she can keep looking after Inaya:
- ●Reaction: "Worse how? I'm already puffed on the stairs. What would mean I need to ring?" She asks: "Am I alright to keep having her? I'm frightened I'll come over funny carrying her up the stairs." Once tests are agreed: "And if it is something, can they sort it out?"
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 / 24 indicators checked+0−0
Positive (0/12)
Negative (0/12)
Domain 3: Relating to Others
0 / 14 indicators checked+0−0
Positive (0/7)
Negative (0/7)
Clinical Learning Points
1
The Core Dilemma: A Request for Tablets That Hides a Red Flag
- ●Parveen has new iron deficiency anaemia 18 years after her menopause, with ten weeks of looser, more frequent stools. She asks only for iron because it worked in her pregnancies and because she cannot see how to fit hospital tests around her grandchildren.
- ●Model plan: start iron today, offer a faecal immunochemical test (FIT) this week, request coeliac serology and a urine test, make a referral plan whatever the FIT shows, explain why it should not wait three months, and plan around Inaya, Saima and Adil. Giving her the iron is part of the right answer. The error is giving it instead of investigating.
- ●Also acceptable: urgent referral to gastroenterology with the FIT requested at the same time, or referral on the suspected cancer pathway whatever the FIT shows.
2
Confirming Iron Deficiency and Judging Severity
- ●NICE CKS defines anaemia in non pregnant women as haemoglobin below 120 g/L. A ferritin below 15 micrograms/L is highly specific for absent iron stores; hers is 6. Low MCV supports it, and her normal MCV two years ago and fall in Hb point to new loss.
- ●NT proBNP of 168 ng/L makes heart failure unlikely (NICE threshold 400), and thyroid and kidney results are normal, so her breathlessness is explained by the anaemia unless it persists as Hb rises.
- ●Same day assessment is needed for anaemia with chest pain, breathlessness at rest, syncope, heart failure or active bleeding. Parveen has exertional breathlessness only, Hb 94 and a regular pulse of 84, so she can be managed in the community. She can keep looking after Inaya with pacing, resting on the stairs and avoiding carrying the child up them.
3
Why Iron Deficiency After the Menopause Is Always Investigated
- ●The BSG guideline (2021) reports that about a third of men and postmenopausal women with iron deficiency anaemia have an underlying cause, most often in the gut, with cancer found in 8% to 10%. Ulcers, oesophagitis, inflammation, angiodysplasia and coeliac disease make up much of the rest.
- ●CKS says a diagnostic trial of iron should not be used after the menopause, and a good response does not exclude a bleeding lesion. Her pregnancy anaemia is not reassuring now, as she has neither periods nor a pregnancy.
- ●CKS advises referring all postmenopausal women with iron deficiency anaemia to gastroenterology and investigating more urgently when Hb is below 100 g/L, as hers is.
4
FIT for Symptoms Is Not the Screening Kit
- ●NICE NG12 (1.3.1 to 1.3.4) says to offer quantitative FIT to adults with a change in bowel habit or iron deficiency anaemia, and to refer on a suspected cancer pathway if the result is 10 micrograms of haemoglobin per gram or more. It says to offer FIT even after a previous negative result through the screening programme, which tests people without symptoms every two years with a much higher cut off (120 micrograms per gram in England, being lowered to 80 in a phased rollout).
- ●FIT uses antibodies specific to human haemoglobin, so it needs no dietary restriction, and iron tablets are not expected to affect it, so the iron need not wait. It is a single home sample, usually reported within about 10 days.
- ●FIT has false negatives. NG12 1.15.1 asks whoever orders the test to take, or pass on, responsibility for acting on the result.
5
The Pathway After the FIT
- ●The BSG and ACPGBI 2025 guideline recommends FIT and coeliac serology in primary care before referral. At 10 or above, refer on the suspected cancer pathway for upper and lower investigation, with the upper endoscopy on the same day where possible.
- ●Below 10 without suspicious symptoms, refer for assessment through an urgent non cancer pathway, because upper endoscopy is still warranted in everyone with iron deficiency anaemia, mainly to find non cancer causes. NG12 1.3.3 adds that a low FIT should not delay referral where ongoing symptoms cause strong concern, so referring on the suspected cancer pathway because her bowel change continues is within guidance.
- ●Investigation is usually gastroscopy with colonoscopy. CT colonography is an alternative for people unsuitable for colonoscopy (BSG 2021). If the kit is not returned, encourage her or send another; if she still cannot, consider urgent referral anyway.
6
The Other Tests Before Referral
- ●Coeliac serology (NICE NG20): IgA tissue transglutaminase with total IgA, accurate only if she eats gluten in more than one meal every day for at least 6 weeks, which she does. Coeliac disease is found in 3% to 5% of people with iron deficiency anaemia, and people aged 50 or over with marked anaemia still need gastroenterology assessment even if it is found.
- ●Urine for blood (CKS), because a small proportion have a renal tract cancer.
- ●Referral forms often ask for abdominal and rectal examination, so offer a face to face appointment without delaying the FIT. NG12 1.5.3 suggests considering CA125 with unexplained fatigue or bowel change.
7
Treating the Iron Deficiency
- ●Start iron straight away; CKS and the BSG say do not defer it unless colonoscopy is within about 2 weeks. Ferrous sulfate 200 mg once daily (65 mg elemental iron), or one tablet of ferrous fumarate or gluconate once daily, reducing to alternate days if not tolerated (BNF). Because her bowels are loose, starting on alternate days is reasonable, with a slower response. Continue for about 3 months after the blood count is normal.
- ●Best absorbed on an empty stomach, or with food if it upsets her; tea, coffee and milk reduce absorption, which matters because she drinks tea with every meal.
- ●Oral iron reduces levothyroxine absorption, so separate them by at least 4 hours (BNF); her 6am levothyroxine and a late morning iron dose fit well.
- ●Warn that iron causes nausea, discomfort, constipation or diarrhoea and darkens the stools. CKS advises warning about safe storage, because accidental iron overdose can be fatal in children, a specific point with a 2 year old in her care. Endoscopy units usually ask her to pause iron before bowel preparation, so she should follow their instructions.
- ●Check the full blood count within 4 weeks. On daily dosing Hb should rise by at least 20 g/L at 4 weeks, or 10 g/L on alternate days (BNF). A good response does not cancel the investigations.
8
Explaining a Suspected Cancer Referral and Why It Should Not Wait
- ●Suspected cancer pathway means a diagnosis or ruling out of cancer within 28 days of urgent referral (NG12). NG12 1.14.1 to 1.14.4 ask clinicians to say they are referring to a cancer service, reassure that most people referred do not have cancer, explain where, how long and what the tests involve, and whether she can bring someone.
- ●Waiting three months for the probation to end would delay a possible diagnosis. Iron may make her feel better, which can make it harder to return to the tests, but it does not treat the source. Bowel cancer, and the polyps that precede it, are far more treatable early.
- ●Her objections are practical and protective. Planning around the grandchildren, and involving Saima and Adil, makes the urgent route achievable.
- ●She can ask for a woman to do the test; units will try but cannot guarantee it. After sedation units ask for a responsible adult to take her home and commonly advise against looking after young children alone for 24 hours.
9
Safety Netting and Follow Up
- ●999: chest pain, breathlessness at rest, collapse, vomiting blood or heavy bleeding from the back passage. Same day: any blood in the stool, black, sticky, tarry stools (iron makes stools dark but formed), fainting, worsening breathlessness, or severe abdominal pain with vomiting.
- ●The clinician who orders the FIT keeps responsibility for the result, a failsafe catches unreturned kits, and she is told how and when she will hear.
10
Common Mistakes in This Station
- ●Prescribing iron as she asks and leaving it there, or planning a trial of iron and investigating only if Hb does not rise.
- ●Accepting the normal screening kit 18 months ago as reassurance, or not knowing that NG12 recommends FIT even after a negative screening result.
- ●Telling her a FIT below 10 means no further tests, when she still needs gastroenterology assessment.
- ●Agreeing to put the investigations off for three months until the probation ends.
- ●Forgetting coeliac serology and a urine test, or advising her to stop eating gluten first.
- ●Prescribing iron without separating it from levothyroxine or warning her to keep it away from a 2 year old.
- ●Avoiding the word cancer when she raises it, or saying it is almost certainly nothing.
- ●Vague safety netting that does not separate black tarry stools from the dark stools iron causes.
Mapped to the RCGP curriculum topic: Haematology.
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