Anaemia
History OSCE Guide
What this station is testing?
In an anaemia history station, the examiner wants to see that you can:
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Assess severity and functional impact
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Ask about symptoms of low haemoglobin
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Look for blood loss, including GI, urinary and menstrual bleeding
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Ask about diet, malabsorption, pregnancy, chronic disease and medication
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Screen for red flags such as malignancy, significant bleeding or haematological disease
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Summarise the likely cause and suggest appropriate investigations
Anaemia histories have two jobs:
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Assess severity.
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Look for the cause.
“Can you tell me what has brought you in today?”
Then explore the symptom.
ONSET
“When did the tiredness start?”
“Did it come on suddenly or gradually?”
Anaemia often develops gradually over weeks or months. Sudden symptoms may suggest acute blood loss or another acute problem.
PROGRESSION
“Has it been getting better, worse or staying the same?”
“Is there anything you could do before that you can’t do now?”
This helps you assess severity and impact.
EXACERBATING & RELIEVING FACTORS
“What tends to make the tiredness worse?”
“Does rest or sleep help?”
“Are you still tired even after sleeping?”
Anaemia-related fatigue often does not fully improve with sleep.
ASSOCIATED SYMPTOMS
“Are you getting short of breath when walking or climbing stairs?”
“Have you noticed your heart racing or beating strongly?”
“Have you felt dizzy or light-headed?”
“Have you fainted or nearly fainted?”
“Any chest pain?”
“Are you managing your usual activities?”
Chest pain, syncope, breathlessness at rest or marked functional decline suggests more severe anaemia or another serious cause.
Explore the Presenting Complaint using OPERA
Look for Blood Loss
A key part of an anaemia history is asking about bleeding.
Ask:
“Have you noticed any bleeding from anywhere?”
Then check specifically for:
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Vomiting blood
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Black, sticky or tar-like stools
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Fresh rectal bleeding
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Blood in the urine
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Coughing up blood
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Nosebleeds
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Easy bruising or unusual bleeding
If there is bleeding, clarify how much, how often and for how long.
Menstrual and Gynaecological History
In patients who have periods, ask sensitively about heavy bleeding.
Useful questions include:
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“Would it be okay if I asked about your periods?”
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“Are your periods heavy?”
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“Do you pass clots?”
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“Do you ever bleed through protection or need to change overnight?”
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“Has this changed recently?”
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“Do you get significant pain?”
In someone who is post-menopausal, ask:
“Have you had any vaginal bleeding since your periods stopped?”
Post-menopausal bleeding is a red flag.
Diet, Malabsorption and Systemic Symptoms
Diet can give clues to iron, B12 or folate deficiency.
Ask:
“What would you eat in a typical day?”
Then ask whether they eat meat, fish or green vegetables, whether they follow a vegetarian or vegan diet, and whether their appetite or diet has changed.
Also ask about features that may point towards malabsorption, chronic disease or malignancy:
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“Any diarrhoea, bloating or abdominal pain?”
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“Any weight loss, fevers or night sweats?”
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“Any change in bowel habit?”
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“Any reduced appetite?”
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“Any mouth ulcers, sore tongue, numbness or tingling?”
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“Any joint pains, rashes or long-term inflammatory conditions?”
These questions can point towards coeliac disease, inflammatory bowel disease, malignancy, chronic inflammation or B12 deficiency.
Past Medical and Surgical History
Ask about general medical background, then focus on conditions that may explain or contribute to anaemia.
Relevant areas include:
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Previous anaemia
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Previous iron tablets, iron infusions or blood transfusion
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Pregnancy, where relevant
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Systemic Disease : Kidney, liver, thyroid, cancer
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Bowel disease
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Coeliac disease
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Inflammatory bowel disease
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Long-term inflammatory disease
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Previous stomach or bowel surgery
If they have had anaemia before, ask what caused it and how it was treated.
Previous stomach or bowel surgery is important because it can affect absorption of iron, B12 or folate.
Drug History and Allergies
Ask about regular medications, over-the-counter treatments, supplements and allergies.
Important medications include:
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Anticoagulants, such as warfarin, apixaban or rivaroxaban
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Antiplatelets, such as aspirin or clopidogrel
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NSAIDs, such as ibuprofen or naproxen
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Steroids, where relevant
Also ask:
“Do you take iron tablets, vitamin B12, folic acid or multivitamins?”
Always clarify allergies and the reaction.
Family History
Ask about family history of anaemia, blood problems, bowel cancer, coeliac disease or inflammatory bowel disease.
If there is a family history of bowel cancer, ask sensitively about age at diagnosis.
Social History and Impact
In anaemia, social history should focus on function and possible contributing factors.
Ask:
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“How is this tiredness affecting your day-to-day life?”
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“Are you managing work, university, caring responsibilities or normal activities?”
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“Who is at home with you?”
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“Do you drink alcohol? If so, how much in a typical week?”
Alcohol is relevant because it can contribute to nutritional deficiency, liver disease and macrocytosis.
Ideas, Concerns and Expectations
Ask naturally:
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“Had you any thoughts yourself about what might be causing this?”
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“Is there anything in particular you’re worried about?”
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“What were you hoping we might be able to do today?”
If the patient is worried about cancer, bleeding or not coping, acknowledge it:
“I can understand why that would worry you. We’ll take it seriously and work through what could be causing the symptoms.”
Red flags in an anaemia history
Important red flags include:
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Black, tarry stools (Upper GI Bleeding)
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Fresh rectal bleeding
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Vomiting/coughing up blood
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Blood in the urine (haematuria)
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B Symptoms (Weight Loss, Night Sweats, Fevers)
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Change in bowel habit
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Post-menopausal bleeding
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Severe breathlessness
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Chest pain
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Syncope
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Symptoms at rest
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Easy bruising, recurrent infections or unusual bleeding
These features should make you think about serious causes such as GI bleeding, malignancy, haematological disease or significant acute blood loss.
Example Summary:
“Patricia is a 19-year-old university student presenting with a three-month history of worsening tiredness. She reports exertional breathlessness and light-headedness, which are affecting her ability to attend lectures and socialise. She has a limited diet since starting university and describes heavy periods with clots, which have worsened over the last six months. She denies rectal bleeding, haematemesis, haemoptysis, weight loss or night sweats. Overall, I would be concerned about anaemia, particularly iron deficiency anaemia secondary to heavy menstrual bleeding and possible dietary deficiency.”
Examiner Questions
Q1: What are your top differential diagnoses?
My main concern would be anaemia.
In a young woman with tiredness, exertional breathlessness, light-headedness, limited diet and heavy periods, iron deficiency anaemia would be most likely.
I would also consider B12 or folate deficiency, hypothyroidism, pregnancy, chronic disease, GI blood loss and less common causes depending on the wider history.
Q2: What symptoms suggest anaemia?
Fatigue, breathlessness on exertion, palpitations, dizziness, light-headedness, headaches, fainting, pallor and reduced exercise tolerance.
Q3: What causes of blood loss would you ask about?
Heavy periods, post-menopausal bleeding, rectal bleeding, black stools, vomiting blood, coughing up blood, blood in urine, nosebleeds, easy bruising or unusual bleeding.
Q4: What initial investigations would you request?
Initial investigations may include FBC, MCV, ferritin and iron studies, B12 and folate, U&Es, LFTs, CRP or ESR, thyroid function tests, pregnancy test where relevant, coeliac screen if indicated, and FIT or endoscopy referral if there is GI bleeding or bowel cancer concern.
Q5: How would you manage iron deficiency anaemia?
Management depends on the cause.
General principles are to treat the underlying cause, replace iron, give dietary advice, safety-net and arrange follow-up blood tests.
Oral iron is often used first if suitable. IV iron or transfusion may be considered in selected patients depending on severity, tolerance and clinical context.
Basic Anaemia Overview
Have awareness of the different blood results, you may be asked to interpret these
Microcytic : iron deficiency anaemia, thalassaemia, sickle cell disease
Normocytic : acute haemorrhage, anaemia of chronic disease, aplastic anaemias, haemolytic anaemia
Macrocytic : B12/Folate deficiency, alcohol misuse
Quick Anaemia History Structure
A focused anaemia history can be structured around:
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Explore tiredness using OPERA
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Ask about anaemia symptoms
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Look for blood loss
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Ask menstrual and gynaecological history where relevant
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Ask about diet, malabsorption and systemic symptoms
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Ask about PMH, medications and family history
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Ask about social impact
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Screen for red flags
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Explore ICE
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Summarise and suggest investigations if asked
Key Message:
A strong anaemia history is not just about asking if the patient feels tired.
Explore the symptoms, assess severity, look for blood loss, ask about diet and malabsorption, and screen for red flags.
In an OSCE, the aim is to work out the likely cause of the anaemia — not just to name anaemia itself.