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.

Clinical note:
Symptoms: mild skin rash, arthralgias in ankles, photosensitivity rash
Diagnosis: presumptive erythema nodosum (based on biopsy), possible inflammatory arthritis
History of Patient: diagnosed with erythema nodosum in 2004 after biopsy, extensive workup including colonoscopy, prior tibia-fibula fracture unrelated to skin lesions, jaw cosmetic surgery, recurrent skin rash with description suggestive of erythema nodosum, initial high sed rate and CRP, subsequent visits showed no evident abnormality, suspicion of IBD, sarcoid inflammatory arthropathy, and lupus raised, positive ANA, negative lupus serologies, concern for lymphoma led to CT scan (unremarkable), evidence of B12 and iron deficiency, initial prednisone treatment followed by colchicine, skin rash persisted, reevaluation by Dermatology, ongoing investigation for underlying cause of disease, history of varicella and mononucleosis, diffuse periarticular ankle edema, heart murmur detected
Plan of Action: echocardiogram for heart murmur, further discussion on significance of eosinophil aggregations with Gastroenterology, DEXA scan, check vitamin D level, order vitamin D and calcium (deferred), consideration of photosensitivity in rash treatment, discussion on effect of colchicine on pregnancy