Chief Complaint: pain and swelling in ankle and feet, alcohol abuse
Medical History: Patient: 53 year old female
Occupation: art student
History: family history of alcoholism, pain in legs since 1978
Current presentation: Patient has stiffness and swelling in her feet and ankles making ambulation difficult. The pain is 8-9 on a scale of 0-10 with deep, heavy, sharp quality that is worse at night. She can recall no injury or precipitating factors. Feet are cool to touch, soft, pale with non-pitting edema. The patient smokes and drinks six beers a night. She eats cold foods for lunch.
Chief Complaint: frequent sinus headaches, sinus drainage
Western Diagnosis: allergies
Medical History: Marked fatigue, bronchitis, sinus drainage. Her headache is behind the eyes. She also sometimes has one-sided headaches.Digestion-sometimes soft stool, occ hard, dry stool. Marked acid regurgitation, and some abdominal bloating. Patient is markedly overweight and admits that she likes sweets. Her periods are painful, with cramps. She occasionally has one-sided headaches; also has significant neck and shoulder pain. The patient takes Zyrtec and Flonase for her allergies. The Zyrtec makes her tired.
Chief Complaint: joint pain
Western Diagnosis: rheumatoid arthritis
Medical History: Female, 34 years old, physical therapist. Joint pain since she was little. Has seen regular physician. Take low dose prednisone off and on.
Ankle, knee and hip joint pain bother her a lot. Recently the both knee swollen, pain, feeling warm and affecting function.
Chief Complaint: Decreased ROM and pain in ankle
Medical History: Patient had sprained her right ankle 6 months previous to first appointment. She had been to physiotherapy for 5 months without much improvement. ROM was limited to only 20% of normal ROM in both plantar flexion and dorsiflexion. Inversion was limited to about 30% of normal ROM. Pain was rated with testing movements at a grading of 4-5 out of 10. Pain increased with movement and this was particularly difficult as she is a swimming coach and a soccer player. Some swelling was also obvious around the external malleolus.
Chief Complaint: Severe pain, edema and stiffness of various joints for 8 weeks.
Western Diagnosis: Rheumatoid Arthritis
Medical History: Severe pain, edema and stiffness of various joints which were symmetrical and typical of RA. Joints affected included ankles, knees, hips, fingers, wrists, jaw, elbows and shoulders. Patientâ€™s mobility was very poor and she needed considerable help with her personal needs. All activities were painful, the majority severely.
Questioning exam: Dull ache with stiffness. Worse at night. Trigger by coldness and tiredness.
Chief Complaint: Lower extremity numbness, tingling, and pain for 6 years
Western Diagnosis: Peripheral Diabetic Neuropathy
Medical History: 6 years ago the patient was diagnosed with type 2 diabetes; concurrent with his diagnosis he began to experience signs of peripheral neuropathy in his lower limbs which include numbness, tingling and pain in the ankles and feet. The pain pattern is as follows: the toes are numb, the top of the sole and the sole of the feet are numb, and a numb pain and feeling of thickness with pain are felt around the ankle joint. There is also heaviness of the foot. The patient also reports a dull pain in the knees. The pain is on the yin side of the legs and the UB channel. The pain is aggravated by walking and is worse in cold wet weather. The pain is reported as a 6/10. Alleviating factors are warmth and massage.
Chief Complaint: weakness and numbness in the legs
Western Diagnosis: Diabetic Neuropathy
History: Patient is a 61 year old male weighing 235 lbs, diagnosed with type 2 diabetes eleven years ago. Since then he has neuropathies in his lower extremities. In addition, he has pitting edema in his lower extremities, drop-foot in both ankles resulting from a pinched nerve at L4-L5 vertebrae caused by two car accidents.