Chief Complaint: Right hip/side cramps. Secondary complaints: low immunity, left tooth abscess (upper molar #16).
Medical History: Patient involved in MVA at age 14. She was a pedestrian hit by car. Multiple surgeries to repair fractured left femur and pelvis. Removal of left kidney and spleen. Currently, patient takes Chinese herbal supplements only.
Questioning exam: Patient is friendly and always smiles. Her voice sounds apologetic and she seems not comfortable in her body. When asked to show her tongue, patient always coughs, apologizes and says “ah”. Coping style is focused on removing herself from situation with girlish laugh and voice, and apologies.