“I’ve had IBS for years — I just need stronger tablets”

A long-standing "IBS" label PLUS iron-deficiency anaemia is a red flag, not a refill request — IBS does not cause iron-deficiency anaemia, and the cluster here (anaemia, fatigue, mouth ulcers, weight loss, a sister with type 1 diabetes — an associated autoimmune condition, not itself a NICE NG20 testing criterion) points to COELIAC DISEASE being missed for years. The examinable clinical point is testing it RIGHT: coeliac serology (tTG-IgA with total IgA) is only reliable while the patient is still eating gluten, so advise her to KEEP eating gluten (in more than one meal a day for at least 6 weeks, NICE NG20) and NOT to cut it before testing; a positive result leads to gastroenterology referral for confirmatory duodenal biopsy, and the iron-deficiency anaemia must be investigated properly rather than blindly treated with iron. Making the diagnosis matters (untreated coeliac risks anaemia, osteoporosis, subfertility and rarely malignancy). The hidden agenda is exhaustion and a suppressed "something’s really wrong" fear behind a self-sacrificing "no time to be ill" request; reframe from symptom-patching to finding the cause, and offer the genuine hope of a treatable, named diagnosis where a gluten-free diet often transforms symptoms.