History Taking · Intermediate · Haematology

Fatigue in a Young Woman

Practise this PLAB 2 history taking station on Iron Deficiency Anaemia. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in a GP surgery. Miss Hilary Briggs, a 38-year-old woman, presents with three months of increasing fatigue and shortness of breath on exertion. Recent blood tests show microcytic anaemia with low iron stores. Please take a focused history to determine the source of iron loss and discuss management.

Background notes: PMH: Nil significant. Recently diagnosed microcytic anaemia (Hb <12, MCV <76, ferritin low)

What this station tests

  • Taking a thorough menstrual history: duration, heaviness (pad soaking, clots, flooding), frequency, and recent changes
  • Screening for GI causes even when menstrual loss is likely: coeliac screen, bowel symptoms, NSAID use
  • Practical iron replacement advice: timing (with vitamin C, away from tea), side effects (constipation, dark stools), alternate-day dosing if intolerant
  • Addressing the cause alongside the deficiency: gynaecology referral for menorrhagia, Mirena coil as first-line
  • Follow-up FBC at 8 weeks to confirm response to iron therapy

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Iron deficiency anaemia in a premenopausal woman is most commonly caused by menstrual blood loss, but the candidate must also consider and exclude gastrointestinal causes. The key is taking a menstrual history alongside a GI history. Miss Briggs is 38, presenting with 3 months of fatigue and exertional breathlessness. Bloods show microcytic anaemia with low ferritin. Open with: 'Miss Briggs, your blood tests show you are anaemic due to low iron. I want to understand why this has happened so we can treat it properly.'

Core approach

Take a menstrual history first (the most common cause). Her periods have become heavier over the past 6 to 12 months: lasting longer (7 to 8 days instead of 5), heavier flow (soaking through pads, passing clots), flooding at night. Ask about frequency, pain, and intermenstrual bleeding. This history strongly suggests menorrhagia as the cause. Ask about contraception: she uses condoms, not hormonal contraception (which would have helped).

Screen for GI causes, which must not be missed even in a young woman with heavy periods. Any change in bowel habit? Rectal bleeding? Dyspepsia? Weight loss? She should have a coeliac screen (tTG antibody) as coeliac disease is a common and often overlooked cause of iron deficiency. No NSAID use (which could cause GI bleeding). No dark stools.

Assess the impact. She used to run regularly and now cannot manage stairs without breathlessness. She is exhausted after work, her partner is worried, and she has noticed palpitations with exertion. This is significant functional limitation.

ICE: She thinks the heavy periods are the cause (and she is likely right). She is worried about cancer. She wants her energy back.

Closing and safety netting

Management has two components: treat the anaemia and address the cause. Iron replacement: oral ferrous sulphate 200mg two to three times daily (take with vitamin C to improve absorption, avoid with tea/coffee which inhibit absorption). Warn about side effects: constipation, dark stools, nausea. If intolerant, alternate-day dosing or ferrous fumarate.

Address the menorrhagia: refer to gynaecology if heavy periods are persistent and affecting quality of life. Treatment options: hormonal (Mirena coil is first-line for heavy menstrual bleeding, tranexamic acid, combined OCP) or surgical. Discuss preferences. The Mirena coil would both manage the bleeding and provide contraception.

Investigations: coeliac screen, repeat FBC at 8 weeks to confirm iron response. If no response to oral iron or if GI symptoms develop, further investigation (OGD, colonoscopy) may be needed. Safety net: 'If you develop chest pain, severe breathlessness at rest, or feel faint, come in urgently.' Address her cancer concern: 'At your age, with heavy periods and no GI symptoms, the most likely cause by far is the menstrual blood loss.'

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for iron deficiency anaemia. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: Menstrual history taken with quantification (duration, heaviness, clots, flooding). GI causes screened (bowel symptoms, coeliac, NSAIDs). Functional impact assessed. Contraception checked. Cancer concerns explored.

Costs marks: No menstrual history. No GI screening. No coeliac screen. Not quantifying the menstrual loss.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Oral iron with practical advice (vitamin C, avoid tea). Side effects warned. Coeliac screen arranged. Gynaecology referral for menorrhagia. Mirena discussed as dual-purpose solution. Follow-up FBC at 8 weeks.

Costs marks: Iron without cause investigation. No coeliac screen. No gynaecology referral. No follow-up plan.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Addressing cancer concern proportionately. Providing hope about symptom improvement with treatment. Discussing menorrhagia management options with shared decision-making. Acknowledging functional impact.

Costs marks: Dismissing cancer concern. Being vague about recovery. Not offering menorrhagia treatment options.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Not taking a menstrual history. In a 38-year-old premenopausal woman with iron deficiency anaemia, heavy periods are the most likely cause. Candidates who investigate GI causes without asking about periods miss the most common aetiology.
  2. Not screening for coeliac disease. Coeliac disease is a common cause of iron deficiency through malabsorption. A tTG antibody test should be included in the workup. Candidates who do not request this miss an associated diagnosis.
  3. Prescribing iron without addressing the cause. Iron tablets will correct the anaemia temporarily, but if the menorrhagia continues, the anaemia will recur. Candidates who replace iron without referral for the bleeding fail to manage the underlying problem.

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

What is the best way to take an iron deficiency anaemia history in PLAB 2?

Iron deficiency anaemia in a premenopausal woman is most commonly caused by menstrual blood loss, but the candidate must also consider and exclude gastrointestinal causes. The key is taking a menstrual history alongside a GI history. Miss Briggs is 38, presenting with 3 months of fatigue and exertional breathlessness.

Where are marks won and lost in this iron deficiency anaemia station?

Examiners reward: Menstrual history taken with quantification (duration, heaviness, clots, flooding). GI causes screened (bowel symptoms, coeliac, NSAIDs). Functional impact assessed. Candidates are penalised for: No menstrual history. No GI screening. No coeliac screen. Not quantifying the menstrual loss.

Where do candidates most often go wrong in this station?

Not taking a menstrual history. In a 38-year-old premenopausal woman with iron deficiency anaemia, heavy periods are the most likely cause. Candidates who investigate GI causes without asking about periods miss the most common aetiology.

Can I do well in this station without real-world experience of iron deficiency anaemia?

Structure beats experience here. Focus on screening for GI causes even when menstrual loss is likely: coeliac screen, bowel symptoms, NSAID use. Use the domain breakdown on this page to target your preparation, then practise the station aloud so your structure survives exam pressure.

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