So next patient is pamela reddy 1 369369 diagnosis list as previously so next patient is pamela reddy 13 recent blood tests august 2025 alt 7 albumin 45 alp 6 normal urea and electrolytes globin at ast 20 to the list of lfts before and full blood count normal apart from mild neutrophilia robin I'm meet you I'm neil in the seat please alright doctor neil you left before uh-huh in clinic I saw you went came to see us back in august yes of last year have you been since then yeah not too bad thank you good yeah no trouble with the liver or anything like that so I mean no no sign of anything a bit of fatigue but then that's quite normal okay I've actually contacted my gp this morning because I've I've developed another couple of lumps on my arm so okay they've been in touch with me and then good that's good fine they'll be much better than me in lumps on my arm yes I have I've had 1 for a long time which is is is much bigger and you can see it's a fatty lump but these are here mhmm which are not as detectable as that so I'm I'm aware that it's down to me really to men that they're not going to do anything extra to do that so but that said I only filled in a form this morning and I've got an appointment this afternoon so a few lumps in the arm and some fatigue tell me about the fatigue how much is it affecting you I don't know whether it's linked to sometimes I sleep really well but then I have periods where so it it's it's possible linked with that but I think it's more about I know my body has to work much harder at keeping well if if that's of course yeah yeah a right way of putting it and I think sometimes if I've got a little something bruise a little bruise or something else then it kinda has to work a bit more over time to repair that now whether these lumps have got anything to do with that yeah that would be that's another common side effect of azathioprine that we see right and obviously you are immunosuppressed with this azathioprine so that's part of it yeah absolutely but it's again it might be I've just changed my lifestyle in that because I was gonna be 66 so I've not got that meant same mental stimulation so you know if I sit down in an afternoon and yeah monday morning yeah like yeah it's like usually you can kinda go to school you know and yeah but this is kind of a bit more than that so yeah I'm I'm not what do plan to do with your time well my husband's decided to stay working for 2 and a half days a week thursday and we're we're trying to do things either day during the day or going away so we've got a few little oh you know so try and get in I mean you're in a gorgeous part of the world aren't you oh absolutely might as well be the most of it yeah yeah so we we try and do something with ourselves every week over the weekend and it and that gives me then 2 and a half days to do more boring stuff like housework sounds like you have a good plan for you hopefully I wonder whether it's worth investigating this fatigue that you've got I know that it sounds like it's something that you've dealt with for a while we know that lots of people with autoimmune hepatitis do complain of fatigue sometimes we find a cause underlying it that's low vitamin a ace thyroid levels or slightly higher levels of a toxic metabolite things that we can tinker with to try and optimize things so I think it's probably worth investigating that yeah absolutely I can get some blood tests from you so if that's okay and we can see whether there's anything that we can correct but often there isn't anything to correct it's a part of your body's reaction to ongoing inflammation and immunosuppression I did I mean normally before coming the letter's so late that when I looked there weren't any but I knew that I'd had you had some in august yeah I'd had which are great so you're they call them a general health like a health check yeah health check so they've they've done quite a lot of different blood tests so I thought that that would probably be your liver tests are your liver tests are great no problem with your liver tests whatsoever and clearly what we're doing is working and we know we tried to bring off the azathioprine unfortunately yes your liver was unhappy so you've gone back on to it yeah mean it's like doctor neil says know I seem to manage really well on the tablets it would just be nice not to take of course yeah I mean since being diagnosed haven't had any other so you know diet wise generally I mean we all have our little of course but I try to balance that by not being know I'm doing sounds like what you're doing is working really well certainly in terms of your liver tests we checked your thyroid which is lovely the thing we haven't checked is your vitamin d right and that can be low in the context of azithioprine haven't checked your azithioprine levels we can do that today or we can do it next time you get some blood tests with gg don't really mind it's completely up to you but it can be changed I'm easy either way I do have to what I used to do for many years was I had 1 in the morning and 1 at whatever reason they decided to just take 1 now at night okay too much you know it's all that kind thing isn't it yeah I mean it's it's it's yeah you know possible that there's not many other things to to see if we can correct to get you feeling better I'll be good yeah because obviously we were aiming for and we don't want to have you feeling fatigued yeah I mean things like you know I've got very healthy nails and things like that so that tends to be 1 of the yeah in terms of calcium certainly yeah and then in terms of the fibroscan there was a plan for you to have a fibroscan I think well oh no that was back in 2021 I'm looking at age but there certainly wasn't any sign of fibrosis developing and stiffness in the liver at test but that was sometime later okay okay I I had I did have a biopsy that doctor nee organized I'd only ever had 1 yeah and that was right at the very beginning when I was first mhmm and this 1 back in 2023 gosh is it that is the most recent 1 I have wow but reassuringly there's no sign of stiffness developing in the liver and no other causes of liver trouble so and it showed that there's no increase in the inflammatory cells even so clearly what we were doing to the immunosuppression was really working there so I suggest we carry on as we are don't change too much because it seems to be working well to control your liver look for other causes of fatigue to try and correct and see you back again back in clinic I'll chat to doctor neil he may say given everything's so good he'll see you in a year but I I won't change the plan but he's made to see you every 6 months and then we'll just keep that rolling but he may say a year is better in which case I'll let you know in the letter brilliant okay absolutely to go through the blood tests and things I don't no we take them up here if you just go through the waiting room you were and just go right there's a big sign that says blood test and I'll grab a blood test brilliant thank you and you see you later requesting lftvc very hello are you putting your blood on for pamela I am if that's okay I'm just doing it now is that alright she's just in with me I've taken her to you soon oh thank you sorry it's my fault for sending her out to you soon