病历_5_3_31
{"patientName":"Ritu Singh","Patient Basic Information":"Name : Ritu Singh\nGender : Female\nAge : Unspecified\nConsultation Date : 2021-XX-XX (Date unspecified in conversation)","Chief Complaint":"Muscle pain, numbness in hands and feet, tingling, and stiffness in calf muscles.","History of Present Illness":"Onset of symptoms: Symptoms started after initial diagnosis of Crohn's disease.\nSymptom description: Muscle pain in various areas, numbness in hands and feet, tingling and pins-and-needles sensations, stiffness in calf muscles, particularly worsens with specific movements like cooking. The skin has also been feeling quite sensitive, with a burning sensation and the appearance of a rash.\nAggravating/Alleviating factors: Symptoms worsen after prolonged sitting or certain movements.\nPrevious management: Started SkyRizi infusions (2 infusions so far) for Crohn's disease.\nAdditional context: Symptoms were present before starting Crohn's treatment but seem to have worsened after it.","Past Medical History":"Diagnosed with Crohn's disease. No prior family doctor before the diagnosis.\nMedication History : SkyRizi infusions for Crohn's disease.","Personal History":"[No lifestyle habits discussed].","Family History":"[Not mentioned].","Physical Examination":"Vital signs: [Not discussed].\nExamination findings: [Not conducted during the visit].","Auxiliary Examinations":"Colonoscopy: Performed (details not specified).\nRoutine Lab Work: Hemoglobin and MCV normal, ferritin level normal, serum iron normal, TIBC normal, but iron saturation is low at 8%.","Diagnosis and Assessment":"Preliminary Diagnosis : Peripheral neuropathy possibly linked to Crohn's disease or medication side effect.\nDifferential Diagnosis : Rheumatologic issues, peripheral neuropathy, enthesitis, spondyloarthritis.","Treatment Plan":"1. Medications :\n- None prescribed during this visit.\n2. Lifestyle Interventions :\n- Not discussed.\n3. Further Examinations :\n- Referral to rheumatology.\n- Lab tests to check Vitamin B12, Folate, Vitamin D, Thyroid function, and Hepatitis screening.","Notes":"Referral to a rheumatologist to rule out autoimmune or rheumatologic issues possibly related to Crohn's disease.\nAwaiting results from ordered laboratory tests. Follow-up appointment scheduled for next Monday."}