病历_3_3_41
{"patientName":"** Ritu Singh","plaintext":"# Medical Record\n## Basic Information\nPatient Name: Ritu Singh\nAge: Not specified\nGender: Female\n## Chief Complaint\nMuscle pain, numbness in hands, and tingling sensations, experienced since the onset of her Crohn's disease.\n## History of Present Illness\nThe patient reports having muscle pain and numbness in both hands and soles of the feet. There is also numbness in the shoulders and around the pelvic area, especially after sitting for extended periods. Pain in the elbow, forearms, and stiffness in calf muscles is noted. Tingling and pins-and-needles sensations in the hands. Pain occurs during specific activities such as cooking. Symptoms have been present since the start of Crohn's disease and have worsened after beginning medication (Skyrizi).\n## Past Medical History\nDiagnosis of Crohn's Disease confirmed by colonoscopy due to the presence of blood in stool. The treatment began in September with two infusions of Skyrizi.\n## Personal and Family History\nFamily history is not provided.\n## Physical Examination\nThere is muscle tenderness upon palpation over the bone area near the joints. No further physical examination details were provided.\n## Auxiliary Tests\nRecent laboratory tests show normal hemoglobin levels and MCV. Iron saturation is low at 8%, but ferritin and iron levels are within normal limits. Vitamin B12, Vitamin D, and thyroid function not yet tested.\n## Diagnosis and Assessment\nThe symptoms could be indicative of peripheral neuropathy, potentially associated with Crohn's disease. The possibility of rheumatological issues such as spondyloarthritis or enthesitis linked to Crohn’s is considered.\n## Treatment Plan\n1. Laboratory Orders: Tests for Vitamin B12, Vitamin D, thyroid function, and screening for hepatitis A, B, and C.\n2. Referral: The patient will be referred to a rheumatologist for further evaluation to rule out rheumatological diseases potentially related to Crohn's disease.\n3. Follow-Up Appointment: Scheduled for next Monday for reviewing lab results and discussion of further management.\n## Physician\nName: Dr. Jia\nDate: Not specified\n"}