Physician's Assistant

Refined clinic letter Fri 02 January 2026 10:32

Last Modified: 94 days ago

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Content:

Diagnosis:
Iron deficiency anaemia - 2024
Metabolic-associated steatotic liver disease (fatty liver)

Other Medical Diagnoses:
• CKD stage 3 - eGFR 39
• CPAP at night for obstructive sleep apnoea
• Decompensated right sided heart failure with severe tricuspid regurgitation - 2023
• Gout
• Atrial fibrillation
• Obesity (December 2025), 
• Lymphoedema
• Haemorrhoids

Current Medications:
• Bendroflumethiazide [dose unknown] PO [frequency unknown]
• Ferrous sulfate 200mg tablets PO [frequency unknown] - STARTED December 2025
• Dapagliflozin [dose unknown] PO [frequency unknown]
• Spironolactone 25mg PO [frequency unknown]
• Allopurinol [dose unknown] PO [frequency unknown]
• Alfuzosin [dose unknown] PO [frequency unknown]
• Bisoprolol [dose unknown] PO [frequency unknown]
• Rivaroxaban [dose unknown] PO [frequency unknown] - STARTED July 2021
• Co-codamol [dose unknown] PO [frequency unknown]

Investigations:
• FIT test: 130 
• Creatinine: 116 with eGFR 39, Potassium 3.1, Urea 16.2
• Ultrasound abdomen: Liver nodular outline suggestive of cirrhosis, no ascites or focal mass, patent portal vein, spleen 13.7cm
• NT-proBNP: 1,091
• Ferritin: 20
• Transferrin saturation: 5% with high transferrin level 3.8
• FBC: Haemoglobin 109, MCV 82.9

On Examination:
BMI 39.5 height 172cm, weight 117kg

Management Plan:
1. CT abdomen and pelvis with 2 days gastrograffin preparation
2. Upper GI endoscopy
3. Blood tests including TTG to exclude coeliac disease
4. Follow-up based on investigation results

Dear GP,

I had the pleasure of speaking on the telephone to Mrs Furse today in iron deficiency anaemia clinic on behalf of Dr Powles.

Many thanks for referring her with her long-standing anaemia since at least 2024 which has recently been tested and found to be a pattern of iron deficiency. Of note she doesn't have any microcytosis however the low ferritin combined with low transferrin saturation and high transferrin level are quite suggestive of absolute iron deficiency. Thank you for starting her on some iron replacement last month.

In terms of her health more generally, Mrs Furse has been struggling with the metabolic syndrome with valvular heart disease, oedema, atrial fibrillation, obstructive sleep apnoea, CKD and obesity. She is losing some weight intentionally at the moment and I note that her most recent weight from you gave her a BMI of 39.5.

She tells me that she uses co-codamol for pain in her joints and this leads to her becoming very constipated. She strains to pass stool, has piles and has noticed some bright red blood coating her faeces. It was at this time that she took her FIT test which has come back raised.

She drinks minimal alcohol, does not smoke, lives alone. She has obstructive sleep apnoea and is prescribed CPAP at night but doesn't use it at the moment. She has significant what she describes as lymphoedema but may be oedema due to her cardiac disease given she's been prescribed spironolactone and furosemide, and she describes the oedema is affecting her bilateral legs and abdomen.

She's recently undergone an ultrasound scan which has demonstrated evidence of liver disease and so we're awaiting a fibroscan in order to investigate that in more detail which sounds sensible.

I explained to her today that her iron deficiency anaemia does put her at a slightly increased risk of malignancy as well as her high FIT test.

I would suggest that the anaemia and iron deficiency is most likely to be due to her liver disease and the high FIT test is most likely to be due to her haemorrhoids. However, it'll be prudent to investigate these and so we have agreed that she'll have a CT abdomen and pelvis with 2 days of oral contrast preparation and an upper GI endoscopy. I look forward to seeing the results of these tests and will be in contact with them but haven't booked her to see her in clinic again.

Finally, she should have some blood tests including a TTG in order to exclude coeliac disease as a cause of low iron levels. I've offered for her to have these taken at the hospital and she'll either book with phlebotomy here or you may be kind enough to facilitate these tests at the practice.

Yours sincerely

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Investigations:

Refined clinic letter Fri 02 January 2026 10:32

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