Progressive exertional breathlessness and fatigue, with heavy menstrual bleeding, suggest iron deficiency from chronic blood loss.
Confirm with blood tests; assess the cause of the bleeding.
Exertional breathlessness remains compatible. Clarify orthopnoea, ankle swelling and cardiac history; these have not yet been explored.
Ask about episodic wheeze, chest tightness and triggers before ranking this alternative.
Pulse, blood pressure, respiratory rate and oxygen saturation; look for pallor and signs of haemodynamic compromise.
Look for raised JVP, oedema, crackles or wheeze. Further examination should follow the bleeding history.
Assess haemoglobin, red-cell indices and iron stores. Interpret ferritin in context if inflammation is suspected.
Investigate the bleeding source; further tests should follow the history and examination.
Assess stability first. If iron deficiency is confirmed, start oral iron and arrange assessment and treatment of the heavy bleeding.
Recheck haemoglobin in 2-4 weeks. Escalate for chest pain, syncope, breathlessness at rest or ongoing heavy bleeding.
What brought you in today?
You let the patient describe the problem in their own terms. Keep that opening before moving to focused questions.
I've been getting out of breath on my walks. It's not like me.
Clarify breathlessness at rest, chest pain and collapse before continuing a routine history. These have not been assessed in this excerpt.
When did you first notice it?
You asked about onset, but "a few weeks" remains imprecise. Clarify duration and whether the deterioration has been steady or sudden.
A few weeks ago. Now I have to stop halfway up the hill.
Compare usual walking distance with current stopping distance, and ask whether symptoms settle with rest. This gives a baseline for review.
How else has this affected your day?
This opens the conversation beyond a symptom checklist. Explore what the patient volunteers before switching to the next diagnostic question.
I'm exhausted. My periods have been much heavier lately, too.
Clarify duration, flooding, clots and bleeding between periods. Menstrual loss is a possible cause, not a reason to stop investigating.
You elicited progression and a possible bleeding source. Next, establish severity and test the working diagnosis rather than closing early.
Quantify the bleeding and explore cardiorespiratory alternatives.
A new question. A different turn. Put your thinking to the test.
A patient has microcytic anaemia, a raised CRP and ferritin within the laboratory reference range. Can iron deficiency be excluded? Explain how hepcidin changes iron availability, and which findings distinguish absolute iron deficiency from inflammation-related iron restriction.
What if haemoglobin has not risen after four weeks of oral iron, despite reported adherence? How would you distinguish ongoing blood loss, malabsorption and an incorrect diagnosis, and what would justify intravenous iron rather than another oral course?
