system: You are a clinical documentation assistant. Generate only the requested clinical note section using only facts from the dialogue. Do not invent information. If the section is not supported by the dialogue, return N/A.

user: Section: GENHX

Dialogue:
Doctor: Hello, miss. Doctor X and I will be going over your medical history with you. Before we begin, could you confirm your age for me?
Patient: I'm twenty five years old.
Doctor: Thank you. Doctor X, could you go over the diagnosis of erythema nodosum?
Doctor_2: She was diagnosed in two thousand and four after a biopsy was done that confirmed erythema nodosum, but the detail from the Netherlands is not that specific.
Doctor: What kind of procedures were done to address it?
Doctor_2: She had undergone a colonoscopy to address secondary diseases that may have been present because of the erythema nodosum, correct miss?
Patient: Yeah, that's correct.
Doctor: Were there any findings, Doctor X?
Doctor_2: The findings were uncertain if the terminal ileum had abnormal biopsies. However, the skin biopsy mentioned some fibrosis, basal proliferation, and inflammatory cells in the subcutis.
Doctor: I see. Her report states something about a tibia and fibula fracture on her right leg before the erythema nodosum. Are these skin lesions due to the fracture?
Doctor_2: The skin lesions are not associated with the fracture, correct ma'am?
Patient: That's correct. The cuts in my skins are on both legs too. Not just the right.
Doctor: Thank you. Did anything occur before the skin lesions?
Doctor_2: She had cosmetic surgery done on her jaw.
Doctor: Ma'am, I see you visited our clinic and the Dermatology several times, correct?
Patient: Yeah, that's correct. I had a rash that I wanted to get checked.
Doctor_2: I remember that. I was here when she presented the rash. We suggested the rash in her lower extremities and ankles was erythema nodosum. She also had discomfort, which could have been inflammatory arthritis.
Doctor: Doctor X, did you confirm with any tests?
Doctor_2: Yes. There was an initial S E D above one hundred and ten and her C P R was increased.
Doctor: Great. In the visits after, were there any other problems found?
Doctor_2: The reports says that no other abnormalities were found. However, I do see something about her first visit.
Doctor: Could you explain what it says?
Doctor_2: She has some M T P detected, which could have been signs of erythema nodosum. However, the Dermatology did not agree, and they believed it to be venous stasis.
Doctor: The venous stasis could have been related to the fracture, right?
Doctor_2: That is correct.
Doctor: Her initial visit reports suspicion of I B D, sarcoid inflammatory arthropathy, and lupus. Why was that?
Doctor_2: She had a questionable rheumatoid fracture even though her C C P was negative. Her A N A was positive at one to four zero. There was a persistent speckled pattern. However, the rest of the lupus serologies were negative.
Doctor: What lupus serologies were used?
Doctor_2: Double stranded D N A, R N P, Smith, R O, and L A were used.
Doctor: How did her cardiolipin antibodies panel look?
Doctor_2: They were all negative. We made sure I g M, I g G, and I g A were less than ten.
Doctor: I see. Was there anything else in the report?
Doctor_2: She had her beta 2 glycoprotein one or R V V T tested.
Doctor: That seems important because of the livedo pattern.
Doctor_2: Exactly. That's why they concluded it was an onset of lupus and not rheumatoid arthritis because the arthritis couldn't be associated with erythema nodosum.
Doctor: Why did she undergo a C T scan?
Doctor_2: We feared she had lymphoma. The scan of her chest, abdomen, and pelvis were done to rule out sarcoid.
Doctor: I see. The results came out normal, right?
Doctor_2: That's correct.
Doctor: Did you change some of you habits to help your bowels, ma'am?
Patient: I tried my best to.
Doctor: That's good. What was found Doctor X?
Doctor_2: There was evidence of B twelve deficiency with a high methylmalonic and high homocystine levels along with a low normal B twelve in addition to iron studies consistent with iron deficiency and an initially low M C V.
Doctor: That gives the possibility of inflammatory bowel disease, right?
Doctor_2: Correct. That's stated in the report.
Doctor: Were there any tests done to confirm this?
Doctor_2: She underwent a colonoscopy, which showed nothing. Her endoscopy was also normal. Recently, she underwent a second coloscopy, and no evidence of inflammatory bowel disease was seen after viewing it microscopically.
Doctor: Nothing was seen microscopically?
Doctor_2: Actually, we determined there were aggregates of eosinophils.
Doctor: That sounds important. That could be due to an allergic reaction or an emergence of Crohn Disease. I will have to discuss with Doctor Y from Gastroenterology to see the significance.
Patient: Could I interrupt for a second? I don't think my B twelve and iron deficiency were looked at while I stayed in the United States.
Doctor: Is that correct, Doctor X?
Doctor_2: That is. I think these details were from somewhere else.
Doctor: At least we are aware of it. What medication was provided during her first visit?
Doctor_2: It looks like she was placed on forty milligrams of prednisone. The strength was reduced over time.
Doctor: This may be a reason to her acne. Was she taken off this medication?
Doctor_2: Yes, she was. There were too many adverse effects.
Doctor: What was she places on after?
Doctor_2: It looks like she started a point six m g colchicine, which she took daily.
Doctor: How were her inflammatory markers after taking it?
Doctor_2: Her markers were under control and positive. She also didn't have any evidence of erythema nodosum.
Doctor: That is great. How did you like that medication, ma'am?
Patient: My ankle would swell up and hurt. There were also some sensitive rashes on the skin of my legs.
Doctor: I see. Is that stated on the report, Doctor X?
Doctor_2: It is. I also see that she was reevaluated by Dermatology.
Doctor: Did they find anything apparent?
Doctor_2: No, they didn't. They didn't find any evidence of erythema nodosum.
Doctor: What was the plan following that?
Docotr_2: It looks like we proceeded with a D E X A scan and checked her vitamin D levels.
Doctor: Was there any medication prescribed?
Doctor_2: We ordered vitamin D and calcium to be bought over the counter so that her bones were protected. However, they use of them was stopped until we figured out the underlying cause of her disease.
Doctor: I see. Other than the fracture and jaw surgery, was there anything else?
Doctor_2: It shows she had Varicella and Mononucleosis, correct ma'am?
Patient: Yeah, that's correct.
Doctor: That's good. Our recent physical exam with you from last August showed changes in your venous stasis and diffuse periarticular ankle edema. Fortunately, we did not find any erythema nodosum, but the livedo patter was still present.
Patient: I see. Did you find anything else?
Doctor: We did find a heart murmur, so we will conduct an echocardiogram. Doctor X, could you confirm all the details form the workup, please?
Doctor_2: Of course. Her A C E levels were normal. Her sed rate was around 30, which was high. Before that, it was around one ten, which is even higher. Her R V V T was normal. The rheumatoid factor was negative. The urinalysis was also normal. She had a C R P level of two point three, which was high. Her C C P came out negative. Her C B C displayed microcytosis and hypochromia with hematocrit levels of thirty seven point seven. Her hematocrit levels improved to forty point three later on, and she did not have any hypochromia, microcytosis, or anemia present.
Doctor: Thank you for all that information. Does all this information and history seem to be correct, ma'am?
Patient: Yes. Thank you for going over that in front of me.
Doctor: No problem. I see you're here today regarding some mild but intense skin rashes. You mentioned that you thought it was erythema nodosum, correct?
Patient: Yeah, that's correct. I think it's on my ankles. I also feel some joint stiffness.
Doctor: I will take note of that. You also mentioned something about a rash before. Did you have a rash that was sensitive to U V light, like sunlight?
Patient: That's right. I had it twice when I was in Europe.
Doctor: When did you notice the rashes?
Patient: I was skiing, and my face started to swell up.
Doctor: I see. Do you think it had to do anything with your acne?
Patient: No. My acne was stable after I stopped taking that one medicine and started the other.
Doctor: The prednisone and colchicine we mentioned earlier, correct?
Patient: That's correct.
Doctor: Is there anything else you would like to ask?
Patient: I am trying to get pregnant and would like to know if the medication has any effects on pregnancy.
Doctor: I'll discus that with you right now.
Patient: Actually, could you provide me with a pamphlet? I need to go study for my psychology classes. I have a big test tomorrow.

assistant: This is a 25-year-old woman who is attending psychology classes. She was diagnosed with presumptive erythema nodosum in 2004 based on a biopsy consistent with erythema nodosum, but not entirely specific back in Netherlands. At that point, she had undergone workup which was extensive for secondary diseases associated with erythema nodosum. Part of her workup included a colonoscopy. The findings were equivocal characterizes not clearly abnormal biopsies of the terminal ileum. The skin biopsy, in particular, mentions some fibrosis, basal proliferation, and inflammatory cells in the subcutis. Prior to the onset of her erythema nodosum, she had a tibia-fibula fracture several years before on the right, which was not temporarily associated with the skin lesions, which are present in both legs anyway. Even, a jaw cosmetic surgery she underwent was long before she started developing her skin lesions. She was seen in our clinic and by Dermatology on several occasions. Apart from the first couple of visits when she presented stating a recurrent skin rash with a description suggestive of erythema nodosum in the lower extremities and ankle and there is discomfort pointing towards a possible inflammatory arthritis and an initial high sed rate of above 110 with an increased CRP. In the following visits, no evident abnormality has been detected. In the first visit, here some MTP discomfort detected. It was thought that erythema nodosum may be present. However, the evaluation of Dermatology did not concur and it was thought that the patient had venous stasis, which could be related to her prior fracture. When she was initially seen here, a suspicion of IBD, sarcoid inflammatory arthropathy, and lupus was raised. She had an equivocal rheumatoid fracture, but her CCP was negative. She had an ANA, which was positive at 1:40 with a speckled pattern persistently, but the rest of the lupus serologies including double-stranded DNA, RNP, Smith, Ro, La were negative. Her cardiolipin panel antibodies were negative as well. We followed the IgM, IgG, and IgA being less than 10. However, she did have a beta-2 glycoprotein 1 or an RVVT tested and this may be important since she has a livedo pattern. It was thought that the onset of lupus may be the case. It was thought that rheumatoid arthritis could not be the case since it is not associated with erythema nodosum. For the fear of possible lymphoma, she underwent CT of the chest, abdomen, and pelvis. It was done also in order to rule out sarcoid and the result was unremarkable. Based on some changes in her bowel habits and evidence of B12 deficiency with a high methylmalonic and high homocystine levels along with a low normal B12 in addition to iron studies consistent with iron deficiency and an initially low MCV, the possibility of inflammatory bowel disease was employed. The patient underwent an initially unrevealing colonoscopy and a capsule endoscopy, which was normal. A second colonoscopy was done recently and microscopically no evidence of inflammatory bowel disease was seen. However, eosinophil aggregations were noted in microscopy and this was told to be consistent with an allergic reaction or an emerging Crohn disease and I will need to discuss with Gastroenterology what is the significance of that. Her possible B12 deficiency and iron deficiency were never addressed during her stay here in the United States. In the initial appointment, she was placed on prednisone 40 mg, which was gradually titrated down this led to an exacerbation of her acne. We decided to take her off prednisone due to adverse effects and start her on colchicine 0.6 mg daily. While this kept things under control with the inflammatory markers being positive and no overt episodes of erythema nodosum, the patient still complains for sensitivity with less suspicious skin rash in the lower extremities and occasional ankle swelling and pain. She was reevaluated by Dermatology for that and no evidence of erythema nodosum was felt to be present. Out plan was to proceed with a DEXA scan, at some point check a vitamin D level, and order vitamin D and calcium over the counter for bone protection purposes. However, the later was deferred until we have resolved the situation and find out what is the underlying cause of her disease. Her past medical history apart from the tibia-fibular fracture and the jaw cosmetic surgery is significant for varicella and mononucleosis. Her physical examination had shown consistently diffuse periarticular ankle edema and also venous stasis changes at least until I took over her care last August. I have not been able to detect any erythema nodosum, however, a livedo pattern has been detected consistently. She also has evidence of acne, which does not seem to be present at the moment. She also was found to have a heart murmur present and we are going to proceed with an echocardiogram placed. Her workup during the initial appointment included an ACE level, which was normal. She also had a rather higher sed rate up to 30, but prior to that, per report, it was even higher, above 110. Her RVVT was normal, her rheumatoid factor was negative. Her ANA was 1:40, speckled pattern. The double-stranded DNA was negative. Her RNP and Smith were negative as well. RO and LA were negative and cardiolipin antibodies were negative as well. A urinalysis at the moment was completely normal. A CRP was 2.3 in the initial appointment, which was high. A CCP was negative. Her CBC had shown microcytosis and hypochromia with a hematocrit of 37.7. This improved later without any evidence of hypochromia, microcytosis or anemia with a hematocrit of 40.3. The patient returns here today, as I mentioned, complaining of milder bouts of skin rash, which she calls erythema nodosum, which is accompanied by arthralgias, especially in the ankles. I am mentioning here that photosensitivity rash was mentioned in the past. She tells me that she had it twice back in Europe after skiing where her whole face was swollen. Her acne has been very stable after she was taken off prednisone and was started on colchicine 0.6 daily. Today we discussed about the effect of colchicine on a possible pregnancy.