Station 1 · Tiredness

Candidates: do not open until you have consulted.

Persona and manner

• Hannah Reeve, 42, a primary-school teaching assistant; pleasant, self-deprecating, tired-looking; you laugh off your symptoms and are keen to be “no trouble”.
• You have seen the word anaemia on the app and expect iron tablets to fix it; you want to leave with a prescription.
• You become quieter and more honest when asked about your periods in a matter-of-fact way.

Opening line (verbatim)

• “I saw my bloods on the app and it says I'm anaemic — I thought so, I'm shattered all the time. Can I just get some iron tablets?”

The story

• “I've been tired for a year or more, worse in the last few months. I fall asleep on the sofa at eight. I'm breathless carrying the shopping up the stairs, which is new.”
• “I chew ice all day at work. Everyone thinks I'm mad.” You think it is a funny habit, nothing more.
• Diet is “fine”: you eat meat, three meals a day.
• If asked about your periods, matter-of-factly: heavy for two or three years, worse this year. Seven or eight days; on the worst two days you flood through a super tampon and a pad in an hour; clots the size of a 50p piece; you have had to leave work twice. Cycle regular, 26 days.
• You have never mentioned the periods to a doctor: “My mum was the same. It's just how we are.”
• No bleeding between periods or after sex; no pelvic pain beyond period cramps; no pressure symptoms.
• Bowels normal; no blood in the stool; no weight loss; no abdominal pain; no indigestion; appetite unchanged. No nosebleeds or easy bruising.
• Not pregnant: your husband had a vasectomy. Not trying for children.
• Family: your mother had a hysterectomy at 45 for heavy periods. No bowel cancer, no thyroid disease in the family.

Ideas, concerns and expectations

• Idea: “I'm anaemic because I'm run down and busy.” You have not connected the periods to the anaemia.
• Concern: If pushed: “Is it something serious, like leukaemia? My colleague's husband had that.”
• Expectation: Iron tablets. You would rather not be referred anywhere.

Impact

• Work: a new head teacher and an inspection coming; you do not want to be off sick. “I can't be off — we've got Ofsted.”
• Home: you are asleep before the children's bedtime; your husband does the evenings.
• Mood: “a bit flat”, low energy; you enjoy things when you have the energy; no thoughts of harming yourself.
• Sleep: poor, because you lie awake worrying about work.

Red flags

• Present: Breathlessness on exertion that is new, which the candidate should weigh against the haemoglobin of 96.
• Absent: No bleeding between periods or after sex; no pelvic mass or pressure symptoms; no post-coital pain.
• Absent: No change in bowel habit, no blood in the stool, no weight loss, no abdominal pain, no dysphagia.
• Absent: No bruising, nosebleeds or gum bleeding; no fevers, night sweats or lumps.
• Absent: No chest pain, palpitations or faints.

Hidden facts and their triggers

• The true heaviness of the periods: flooding, clots, two days off work — released only if the doctor asks about periods in a matter-of-fact way; a vague “are your periods OK?” gets “they're fine”
• Your mother's hysterectomy at 45 for heavy periods — released only if asked about the family
• The leukaemia worry from your colleague's husband — released only if the doctor asks what worries you
• The overdue smear: “there's never time” — released only if the doctor raises screening
• The breathlessness on the stairs — released only if asked about exertion or breathing

Behaviour

• Minute 1: laugh — “I chew ice all day, everyone at work thinks I'm mad.”
• Minute 3, if asked about periods: look down — “They're… a lot. I thought that was normal.”
• Minute 6: “I can't be off — we've got Ofsted.”
• If the doctor links the anaemia to the periods, explains the results plainly, starts iron with a repeat count planned, offers something for the bleeding now and discusses the hormonal coil and the other options, arranges an examination and a scan if needed, sends the coeliac test, books the smear and safety-nets: relieved. Ask, “So it's the periods that's done this?” and “Will the coil stop my periods?”
• If the doctor prescribes iron and nothing else: say thank you and leave.
• If the doctor goes straight to a gynaecology referral before offering anything: “Do I really need to go to the hospital?”
• If lectured about the smear: go quiet; answer in single words.

Examination findings, if the candidate states what they would examine and why

• Video: you can show pale conjunctivae if asked to pull down your lower eyelid; your hands look pale.
• If the candidate states what they would examine in person and why: pulse 88 regular; blood pressure 118/74; abdomen soft, no masses; a pelvic examination, if arranged and described, finds a normal-sized uterus and no adnexal mass. Offer to come in; nothing is examined today.

Domain grades — with the key facts that earn a clear pass at this station

Global rating (recorded, not added to the total): ☐ Fail ☐ Bare Fail ☐ Bare Pass ☐ Pass

The domain grades (RCGP descriptors): CP clear pass — above the standard of a newly qualified, independent GP · P pass — sufficiently demonstrated at the standard · F fail — insufficiently demonstrated at the standard · CF clear fail — clearly demonstrated below the standard.

The RCGP grades each domain CF, F, P or CP and weights clinical management and medical complexity against the other two domains; the examination's maximum is 126 over twelve cases, which is 10.5 per case. The RCGP does not publish the mark each grade carries. MD Acumen's training sheet uses CF 0 · F 1 · P 2 · CP 3, with clinical management weighted ×1.5 (0 · 1.5 · 3 · 4.5), so that a case is marked out of 10.5 and a twelve-case circuit out of 126. A P in all three domains is 7.0; MD Acumen treats that line as the training standard for a case. The examination's pass mark is set by borderline regression for each diet and is published in the RCGP's diet summary reports; it is not a fixed fraction of 126.

Weighting rationale, in the RCGP's words: “To reflect the capability coverage within the clinical management and medical complexity domain this is weighted in comparison to the other two domains.”

Written to the standard of a newly qualified independent GP; the clear-pass row describes practice above that standard. It is a debriefing aid, not a checklist: the grade is a judgement that the essentials, the italic key facts on the mark sheet, were done well, at the patient's pace and in plain language. MD Acumen training standard; the RCGP does not publish case mark sheets.

Where candidates lose this station

• Asking about periods vaguely and accepting “they're fine”, so the cause of the anaemia is never found (statement D1)
• Prescribing iron alone, with no plan for the bleeding that caused it and no repeat count (statement C8)
• Lecturing about the overdue smear so that she stops contributing to the consultation (statement R5)

What the examiner is listening for in the last four minutes

By 8:00 the working diagnosis and its cause should have been stated. The examiner is listening for: iron with a repeat count and a date; a treatment for the bleeding she can start now and the coil explained as the first-line long-term option; the coeliac test, the examination and the smear arranged; a safety-net that names breathlessness, chest pain, faints and flooding that does not settle; and a check of understanding in her words, including what the coil would do to her periods.

The ten statements below are postulated: the feedback an examiner would most likely attach at this station, chosen from the RCGP's standardised list of 26 feedback statements that applies to every SCA case and spans the three marking domains (Data Gathering and Diagnosis; Clinical Management and Medical Complexity; Relating to Others). They are a prediction from the case content, its complexity and the marks that matter, not an examiner's record: any statement on the full list can be attached to any case, and feedback plays no part in the mark. Record the statements that applied in the practice log.

The full list of 26 statements, with the generic meaning of each, is on the exam and the mark scheme.

Points of fact the examiner should have to hand

Each statement is drawn from the named guideline, in its current version, with the date it was checked. The examiner marks against these facts; the candidate is not expected to quote them.

1. A haemoglobin below 120 g/L in a non-pregnant woman is anaemia; a ferritin below 15 micrograms/L confirms iron deficiency, and a low MCV with a low ferritin is iron deficiency until proven otherwise. In a premenopausal woman with heavy menstrual bleeding and no gastrointestinal symptoms, menstrual loss is the usual cause; coeliac serology is still sent. NICE CKS — Anaemia, iron deficiency, diagnosis; investigations, current online version, checked 10 Oct 2026
2. Oral iron: one tablet of ferrous sulfate 200 mg (65 mg elemental iron) once daily, or on alternate days if not tolerated; check the full blood count after two to four weeks for a rise in haemoglobin, and continue iron for three months after the haemoglobin has normalised to replenish stores. NICE CKS — Anaemia, iron deficiency, management: treatment and monitoring, current online version, checked 10 Oct 2026
3. Heavy menstrual bleeding: take a history that covers the nature of the bleeding, related symptoms, impact on quality of life, intermenstrual and post-coital bleeding, pelvic pain and pressure symptoms; a physical examination is offered before any investigation or treatment for the bleeding. NICE — NG88 Heavy menstrual bleeding: assessment and management, section 1.1, history and examination, 2018, last updated May 2021, checked 10 Oct 2026
4. Offer the levonorgestrel intrauterine system as first-line treatment for heavy menstrual bleeding with no identified pathology, fibroids under 3 cm or suspected adenomyosis; if declined or unsuitable, consider tranexamic acid or an NSAID (non-hormonal), or the combined pill or cyclical oral progestogen (hormonal). NICE — NG88 Heavy menstrual bleeding: assessment and management, section 1.5, management, 2018, last updated May 2021, checked 10 Oct 2026
5. Consider pelvic ultrasound as the first-line investigation when the uterus is palpable abdominally, examination suggests a pelvic mass, or the history or examination suggests a structural or histological abnormality; a full blood count is taken in all women with heavy menstrual bleeding. NICE — NG88 Heavy menstrual bleeding: assessment and management, section 1.2, investigations, 2018, last updated May 2021, checked 10 Oct 2026
6. Refer on a suspected-cancer pathway for colorectal cancer, or use FIT to guide referral, when there is iron-deficiency anaemia with no obvious cause; in a premenopausal woman with heavy periods the cause is evident, but any change in bowel habit, rectal bleeding or abdominal mass triggers the pathway regardless. NICE — NG12 Suspected cancer: recognition and referral, section 1.3, lower gastrointestinal tract cancers, 2015, last updated 2025, checked 10 Oct 2026
7. Serological testing for coeliac disease is offered to people with unexplained iron-deficiency anaemia, and to people with persistent unexplained fatigue; the person must be eating gluten in more than one meal a day for at least six weeks before testing. NICE — NG20 Coeliac disease: recognition, assessment and management, section 1.1, recognition, 2015, checked 10 Oct 2026
8. Women are invited for cervical screening every three years from 25 to 49 in England (every five years where primary HPV screening applies, from 2025); a woman who has missed an invitation can book at any time and does not need a GP referral. GOV.UK (NHS England) — Cervical screening: programme overview, 2025, checked 10 Oct 2026
9. Offer FIT to adults with iron-deficiency anaemia at any age, and to adults aged 60 and over with anaemia even without iron deficiency. Refer on a suspected-cancer pathway for colorectal cancer when the result is 10 micrograms of haemoglobin per gram of faeces or more. A negative result does not exclude cancer: safety-net, and consider referral if symptoms persist or there is strong clinical concern. NICE — NG12 Suspected cancer: recognition and referral, section 1.3, lower gastrointestinal tract cancers: FIT recommendations (August 2023 update), 2015, last updated 2025, checked 10 Oct 2026
10. In iron-deficiency anaemia the GP sends coeliac serology, tests the urine for blood, and takes a menstrual, dietary and drug history. A premenopausal woman with heavy periods, no gastrointestinal symptoms and no family history of colorectal cancer is treated for the menstrual cause; gastrointestinal investigation is reserved for those with symptoms, a family history, or an anaemia that does not respond to iron. NICE CKS — Anaemia, iron deficiency, management: investigations and when to refer, current online version, checked 10 Oct 2026
11. Oral iron is best absorbed on an empty stomach, an hour before food; tea, coffee, milk and antacids reduce absorption, and taking it with food is acceptable if that is the only way it is tolerated. Warn that the stools turn black and that nausea, constipation or diarrhoea are common. Haemoglobin should rise by about 20 g/L every three to four weeks; if it does not, check adherence and tolerance and consider continuing blood loss or malabsorption. Intravenous iron is for intolerance or failure to respond. NICE CKS — Anaemia, iron deficiency, management: prescribing information and follow-up, current online version, checked 10 Oct 2026
12. Consider testing for a coagulation disorder, such as von Willebrand disease, in a woman who has had heavy menstrual bleeding since her periods began and has a personal or family history suggesting a bleeding disorder. Do not routinely test female hormone levels or thyroid function for heavy menstrual bleeding. Offer outpatient hysteroscopy, rather than ultrasound, when the history suggests submucosal fibroids, polyps or endometrial pathology, for example persistent intermenstrual bleeding. NICE — NG88 Heavy menstrual bleeding: assessment and management, section 1.2, investigations: laboratory tests; hysteroscopy and ultrasound, 2018, last updated May 2021, checked 10 Oct 2026
13. Combined hormonal contraception is UKMEC category 2 from age 40, category 3 in a woman aged 35 or over who smokes fewer than 15 cigarettes a day and category 4 if she smokes 15 or more, category 3 at a BMI of 35 or above, and category 4 with migraine with aura. The levonorgestrel intrauterine system, the implant and the progestogen-only pill are category 1 or 2 in each of these circumstances. FSRH — UK Medical Eligibility Criteria for Contraceptive Use (UKMEC), tables: age; smoking; obesity; headaches, 2016, amended September 2019, checked 10 Oct 2026
14. The Topic Guide 'Gynaecology and breast health' expects the GP to assess and manage menstrual problems, including heavy menstrual bleeding, in primary care: a structured history, examination, ultrasound where indicated, first-line treatment including the levonorgestrel intrauterine system, and recognition of the features that need referral. The Haematology Topic Guide expects the GP to diagnose iron-deficiency anaemia, treat it, and establish its cause. RCGP — GP curriculum: Gynaecology and breast health, menstrual problems and heavy menstrual bleeding; Haematology Topic Guide: anaemia, Being a GP, 2025 curriculum, checked 10 Oct 2026

Working references for this station

14 statements, 785 words. Every statement is signed by the Course Director before it is published; a station whose facts have changed since signature carries no signature line until it is signed again.

Record your three domain grades, your case total out of 10.5, your global rating, the RCGP feedback statements that applied, and what you will keep and change. The form is already labelled with this case and its web address; a copy of your entry is emailed to you, so your practice log builds up in your inbox and can be downloaded.

Record my marks and reflection for SCA-01