PLAB 2: Mastering Anaemia Management Guidelines for OSCE Success

PLAB 2: Mastering Anaemia Management Guidelines for OSCE Success

As an International Medical Graduate (IMG) preparing for the PLAB 2 examination, you know that a comprehensive understanding of common medical conditions and their management is paramount. Anaemia is a ubiquitous presentation in general practice and hospital settings, making it a high-yield topic for your OSCEs. As an examiner, I’ve seen countless candidates struggle not with the knowledge itself, but with its structured application under exam conditions. This guide will help you master anaemia management guidelines for PLAB 2, ensuring you approach these stations with confidence.

Why Anaemia is a PLAB 2 Essential

Anaemia is a clinical sign, not a diagnosis. It’s crucial to identify the underlying cause. In PLAB 2, you'll encounter scenarios requiring you to:

1. Take a focused history.

2. Perform a relevant examination.

3. Formulate appropriate investigations.

4. Outline a management plan based on current UK guidelines.

5. Communicate effectively with the patient.

Navigating the Anaemia OSCE Station: A Structured Approach

1. The Focused History: Uncovering Clues

Your history is key to narrowing down the differential diagnoses. Think systematically:

• Symptoms of Anaemia: Fatigue, breathlessness (especially on exertion), palpitations, dizziness, pallor, cold sensitivity. For chronic anaemia, symptoms might be subtle.

• Onset and Duration: Acute vs. chronic provides clues to aetiology.

• Bleeding History: Crucial! Ask about:

  • Gastrointestinal: Melena, haematochezia, PR bleeding, dyspepsia, NSAID use (consider peptic ulcer, gastritis, colorectal cancer). Remember to ask about change in bowel habits.

  • Gynaecological: Menorrhagia, intermenstrual bleeding, post-menopausal bleeding (PMB).

  • Urinary: Haematuria.

  • Other: Epistaxis, gum bleeding, easy bruising.

• Dietary Intake: Vegetarian/vegan diet (B12 deficiency), poor diet (iron/folate deficiency).

• Medications: NSAIDs, anticoagulants, chemotherapy, drugs causing haemolysis.

• Comorbidities: Chronic kidney disease, inflammatory bowel disease, autoimmune conditions, malignancy, chronic infections (anaemia of chronic disease).

• Alcohol Intake: Can affect nutrition (folate) and bone marrow.

• Family History: Genetic anaemias (e.g., thalassaemia, sickle cell).

• Travel History: Malaria, parasitic infections.

2. The Targeted Examination: What to Look For

While time is limited, a focused examination is vital:

• General Appearance: Pallor (conjunctival, palmar creases), jaundice (haemolysis), glossitis (B12/iron deficiency), angular stomatitis (iron deficiency).

• Hands: Koilonychia (spoon-shaped nails - severe iron deficiency).

• Cardiovascular: Tachycardia, flow murmur.

• Abdomen: Splenomegaly (haemolysis, portal hypertension), hepatomegaly.

• Lymphadenopathy: Suggests malignancy/infection.

• PR Examination: (If GI bleeding is suspected and appropriate for the station) – looking for fresh blood, melena.

3. Essential Investigations: Guiding Your Diagnosis

Your initial approach is usually a Full Blood Count (FBC) with Red Cell Indices (MCV, MCH, MCHC) and a blood film.

• Microcytic Anaemia (Low MCV):

  • Iron Deficiency: Most common. Check serum ferritin (low), iron studies (low serum iron, high TIBC, low transferrin saturation).

  • Thalassaemia/Sickle Cell Trait: Normal ferritin, high red cell count. Haemoglobin electrophoresis.

  • Anaemia of Chronic Disease: Often normocytic, but can be microcytic. Normal/high ferritin.

• Normocytic Anaemia (Normal MCV):

  • Acute Blood Loss: FBC may initially be normal before haemodilution.

  • Anaemia of Chronic Disease: (Most common normocytic in hospitalised patients). Elevated inflammatory markers, normal/high ferritin.

  • Renal Failure: Check renal function (e.g., eGFR, creatinine). Reduced erythropoietin.

  • Haemolysis: Reticulocyte count (high), bilirubin (high), LDH (high), haptoglobin (low), Coomb's test.

  • Mixed Deficiencies: e.g., iron and B12.

• Macrocytic Anaemia (High MCV):

  • Megaloblastic: B12 and Folate levels (low). Common causes: pernicious anaemia, malabsorption (Crohn's, coeliac), gastric surgery, strict vegetarianism (B12), alcoholism, poor diet, certain drugs (e.g., methotrexate, phenytoin) (folate).

  • Non-Megaloblastic: Liver disease, hypothyroidism, myelodysplastic syndromes, alcohol excess, certain drugs.

4. Management Principles: UK Guidelines in Practice

Your management plan will depend entirely on the underlying cause:

• Iron Deficiency Anaemia (IDA):

  • Oral Iron: First-line. Ferrous fumarate/sulfate (e.g., 200mg TDS, adjust as tolerated). Advise taking with vitamin C, avoiding tea/coffee. Counsel on side effects (nausea, constipation, dark stools).

  • IV Iron: Consider if oral iron is poorly tolerated, malabsorption, or rapid correction needed (e.g., pre-operatively). Requires hospital administration.

  • Identify and Treat Cause: Crucial! Referral for GI workup (gastroscopy/colonoscopy) if no obvious cause (e.g., menorrhagia). For PMB/GI bleeding, urgent referral.

• B12 Deficiency Anaemia:

  • Pernicious Anaemia/Malabsorption: Intramuscular Hydroxocobalamin. Initially frequent doses (e.g., 3 times a week for 2 weeks), then maintenance (e.g., every 3 months) for life.

  • Dietary Deficiency: Oral B12 supplementation (often high dose, e.g., 1000mcg daily) or dietary advice.

• Folate Deficiency Anaemia:

  • Oral Folic Acid: 5mg daily until stores replete. Address underlying cause (e.g., diet, alcohol). Always exclude B12 deficiency first, as folate can mask neurological damage.

• Anaemia of Chronic Disease:

  • Primarily manage the underlying chronic condition. Iron supplementation may be considered, but often less effective if ferritin is normal/high.

  • Erythropoietin-stimulating agents (ESAs) in specific cases (e.g., CKD).

• Haemolytic Anaemia:

  • Manage underlying cause. Steroids for autoimmune haemolytic anaemia. Transfusion in severe cases.

• Blood Transfusion: Generally reserved for acute, symptomatic anaemia or Hb <70 g/L (or <80 g/L in specific conditions like ischaemic heart disease/CKD). Always discuss risks and benefits.

5. Patient Education and Safety Netting

• Explain the Diagnosis: In simple, clear language.

• Discuss the Plan: What investigations, what treatment, expected duration.

• Side Effects: Counsel on potential side effects of medications (e.g., iron).

• Lifestyle Advice: Dietary changes (e.g., iron-rich foods, B12 sources).

• Monitoring: Explain follow-up appointments and blood tests.

• Safety Netting: Emphasise when to seek urgent medical attention (e.g., worsening symptoms, new bleeding, severe abdominal pain).

PLAB 2 Tips for Success

• Be Systematic: Follow a clear structure (history, exam, investigations, management, ICE/plan). This shows competence and ensures you don't miss crucial steps.

• Communicate Effectively: Use open-ended questions, listen actively, empathise, and explain complex information clearly. Always check the patient's understanding.

• Prioritise: In a time-limited OSCE, focus on the most relevant questions and examinations. You don't need to do a full head-to-toe exam for every patient.

• Think Safety: Always consider red flags (e.g., alarm symptoms for cancer) and safety-netting.

• Practice, Practice, Practice: Role-play scenarios with peers, focusing on the flow and applying the guidelines under pressure.

Mastering anaemia management for PLAB 2 is about demonstrating a holistic, guideline-driven approach to patient care. By internalising these principles and practicing their application, you'll be well-equipped to ace your OSCE stations and, more importantly, provide excellent care to your future patients in the NHS.