Physician's Assistant

Patient Details

Refined clinic letter (214 days ago 09:05)

Refined clinic letter Thu 04 September 2025 09:05

Last Modified: 214 days ago

MRN:

Content:

Diagnosis:
Autoimmune hepatitis - on maintenance azathioprine therapy

Other Medical Diagnoses:
• Multiple lipomas - arm lesions, GP assessment arranged
• Fatigue - under investigation

Current Medications:
• Azathioprine 50mg PO ON (patient takes at night)

Investigations:
• LFTs (August 2025): ALT 7, Albumin 45, ALP 6 - excellent liver function
• AST 20 - normal
• U&Es (August 2025): Normal
• FBC (August 2025): Normal apart from mild neutrophilia
• Liver biopsy (2023): No increase in inflammatory cells, no fibrosis
• Fibroscan (2021): No stiffness or fibrosis
• Thyroid function: Normal

Management Plan:
1. Blood tests today - vitamin D levels, azathioprine levels to investigate fatigue
2. Continue current azathioprine therapy as liver control excellent
3. Investigate underlying causes of fatigue
4. Next appointment - 6 months (may extend to yearly if stable)

I had the pleasure of seeing Mrs Reddy in gastroenterology clinic today.

She remains well with excellent control of her autoimmune hepatitis on azathioprine maintenance therapy. Her recent liver function tests from August 2025 show excellent results with ALT 7, albumin 45, and ALP 6. Her liver biopsy from 2023 showed no increase in inflammatory cells and no fibrosis development, confirming the effectiveness of her current immunosuppressive regimen.

She reports some ongoing fatigue which she feels may be related to her immunosuppressed state and the effort her body requires to maintain wellness. She has also developed some new lipomas on her arm and has appropriately contacted her GP this morning, securing an appointment this afternoon.

Given her excellent liver control, we will continue her current azathioprine regimen. To investigate her fatigue, I have requested blood tests today including vitamin D levels and azathioprine levels, as these are commonly deficient in patients on long-term azathioprine therapy.

She remains motivated with lifestyle modifications since retirement and has good family support. I will review her again in 6 months, though may extend to yearly follow-up given her stable condition.

Field Clipboard (for EPR paste)

Builds copy buttons from the headings currently in the note, and also lets you copy the entire note.

Summary:

Investigations:

Patient Details

Refined clinic letter Thu 04 September 2025 09:05

Field Clipboard (for EPR paste)

Tasks

Feedback