Ameera Khan
Age: 67 year old female
Examiner
Marking Scheme
Data Gathering and Diagnosis
- Ask why the patient had the blood test done in the first place.
- Ask if there has been any bleeding from any site: nosebleeds, gum bleeding, vomiting blood (haematemesis), coughing blood (haemoptysis), unexplained bruising, blood in stools or black stools, vaginal bleeding, or blood in the urine.
- Ask about any new or recent heartburn symptoms to help rule out a bleeding peptic ulcer or upper gastrointestinal malignancy.
- Ask if the patient is experiencing abdominal pain, vomiting, or difficulty swallowing (Keeping in mind upper GI malignancy)
- Screen for anaemia red flags: “3 head”: light-headedness, headaches, dizziness AND “3 chest”: shortness of breath, chest pain, palpitations
- Ask about other symptoms of anaemia: fatigue, dry skin, changes in hair, mouth ulcers (especially at the corners), or generalised weakness.
- Ask about systemic symptoms: weight loss, loss of appetite, or any recent changes in bowel habits including diarrhoea or constipation.
- Ask about dietary habits (especially iron intake) and any recent changes.
- Ask about smoking and alcohol use.
- Clarify home situation and any recent changes in social support or routine.
- Ask if the patient has recently travelled abroad (to rule out potential causes such as parasitic infection or nutritional deficiencies).
- Explain that the blood test results indicate anaemia, most likely due to iron deficiency.
Example of explanation to patient
Ameera, thank you for coming in today to discuss your blood results. Your blood test shows that you have anaemia, which means your body doesn’t have enough red blood cells or haemoglobin to carry oxygen effectively. In your case, the red blood cells are smaller than usual — a pattern we typically see in iron deficiency anaemia.
Iron deficiency can sometimes be related to diet, especially if you’re not getting enough iron-rich foods like you mentioned. However, when we see this pattern in someone your age, we also want to make sure we rule out any more serious underlying causes, such as slow blood loss in the tummy and bowels or, more rarely, conditions like bowel cancer.
Now, I want to reassure you, I’m not saying this is cancer, but it’s important we rule out anything serious. That’s why I’d like to see you face to face to examine your tummy, if that’s okay with you.
I’ll also arrange a few more tests:
- A blood test to check your iron levels and confirm the diagnosis.
- A FIT test — this is a stool test that checks for tiny amounts of blood in your stool that you wouldn’t see yourself.
- A coeliac screen, as coeliac disease can affect iron absorption.
- A urine test to check for any hidden blood in your urine.
If your iron levels (ferritin) come back low, we’ll likely start you on iron tablets to help replenish your stores. At the same time, I’d refer you to a specialist to look into why your iron might be low. They may suggest doing some camera tests — one that looks at your stomach (called a gastroscopy) and another that looks at your bowels (a colonoscopy). These tests help us rule out any possible bleeding or other issues that might be causing the anaemia.
In the meantime, it might be helpful to think about ways to improve your diet. Iron-rich foods include things like dark green leafy vegetables, fortified breads and cereals, red meat, apricots, prunes, and raisins. If you’re finding it difficult to plan meals, we can also consider a referral to a dietitian for support.
Lastly, if you notice any bleeding from anywhere, like in your urine, stool, or from your gums, or if you develop new symptoms such as chest pain, shortness of breath, feeling dizzy, or your heart racing, it could be a sign that you’re losing more blood. If that happens, please don’t wait — contact the surgery urgently or call 111 for immediate advice.
Management
- Arrange further investigations including ferritin and other haematinics (vitamin B12, folate), coeliac screen, urinalysis to check for blood in the urine, and a FIT test to look for hidden blood in the stool.
- Do not start iron tablets at this stage — we need to confirm whether the anaemia is due to iron deficiency first
- Let the patient know that if iron deficiency is confirmed, treatment will include iron tablets, and she may be referred to a specialist for further testing, which may involve gastroscopy with or without colonoscopy.
- Explain that iron tablets can sometimes cause constipation or dark stools, and if she experiences this or has difficulty tolerating them, she should let the practice know.
- Ask if she’s considered ways to improve her diet, since this could be contributing to her anaemia. Advise her on iron rich foods which includes, dark green vegetables, fortified breakfast cereals, apricots, prunes etc.
- Consider referring the patient to a dietitian for individualized advice on nutrition and incorporating iron-rich foods, if they are open to it.
- Safety net: Advise her to seek urgent medical attention if she notices any bleeding (such as in urine, stool, or from gums), or if she experiences new symptoms like chest pain, shortness of breath, dizziness, light-headedness, or a racing heart.
Arrange follow-up in 2–3 days to review the results of the additional tests and discuss the next steps.
Learning point from this station:
Microcytic anaemia has several possible causes, commonly remembered by the acronym CLIST:
- C – Chronic disease
- L – Lead poisoning
- I – Iron deficiency anaemia
- S – Sideroblastic anaemia
- T – Thalassaemia
Therefore, when microcytic anaemia is identified, it is essential to check ferritin and full iron studies before assuming iron deficiency, as the underlying cause may differ and require a specific management plan.
Iron deficiency can be caused by poor dietary intake, especially in older adults. However, in people of this age group, sinister causes must always be ruled out — particularly gastrointestinal cancers. It is important to note that the referral pathway for suspected upper or lower GI cancer is separate from the urgent referral pathway for iron deficiency anaemia (IDA).
According to NICE guidelines on IDA:
Refer to gastroenterology all men and postmenopausal women with iron deficiency anaemia, unless there is clear evidence of non-gastrointestinal bleeding (e.g. heavy menstrual bleeding or haematuria).
Men with Hb <120 g/L and postmenopausal women with Hb <100 g/L should be investigated more urgently, as lower haemoglobin levels may suggest more serious disease.
Anyone aged 50 years or older with marked anaemia or a significant family history of colorectal carcinoma should be referred to gastroenterology, even if another cause such as coeliac disease is found.
Premenopausal women under 50 should be considered for referral if they:
- Have colonic symptoms,
- Have a strong family history of gastrointestinal cancer (e.g. two affected first-degree relatives or one diagnosed before age 50),
- Have persistent iron deficiency anaemia despite treatment,
- Or do not menstruate (e.g. after hysterectomy).
Please NOTE that referral to gastroenterology for iron deficiency anaemia is usually done urgently (within 2 weeks)
Understanding this distinction helps ensure patients are referred appropriately, serious conditions are not missed, and unnecessary referrals are avoided.
Iron Deficiency Without Anaemia (Non-anaemic iron deficiency)
Some patients may have iron deficiency without anaemia—that is, low ferritin but normal haemoglobin levels. This can be a clinical challenge because the person may not show obvious symptoms, and the condition may go unnoticed for a long time.
In fact, waiting for haemoglobin to drop before acting can delay diagnosis. Iron deficiency usually starts with low iron stores (shown as low ferritin), then progresses to changes in red blood cells like microcytosis (small cells) and hypochromia (paler cells), before finally leading to anaemia.
Ferritin is often the earliest and most sensitive marker of iron deficiency. So, even without anaemia, low ferritin should not be ignored, especially in patients at risk—like older adults or those with GI symptoms—because it may still signal chronic blood loss or an underlying cause like cancer. The referral and management approach for iron deficiency without anaemia is the same as for iron deficiency anaemia