Chief Complaint: big toe hurts, neck pain
Western Diagnosis: sports sprain
Medical History: a football athlete from Steelers, his left big toe hit the ground straight when playing football. No pain killers. Regular diet, no regular rest, a lot of competition
Questioning exam: Pain duration: one month.
Intensity: About 7-8, hurts all the time, ice makes it feel better.
Chief Complaint: Right shoulder pain
Medical History: Patient is a 54 year old female massage therapist seeing 10-15 people per week. She has been seeking help for this problem for the past 2 years with the results being that it takes the pain away yet it always returns. Her outlook is positive and she has healthy diet and exercise habits.
Questioning exam: The pain is worse stress and on palpitations her whole right side is tender along that gallbladder channel. Patient has bouts of insomnia which have no particular cycle.
Chief Complaint: Pain and numbness post-surgery.
Western Diagnosis: Benign brain tumor located superior to l. mastoid process.
Medical History: Patient is a 35-year old female with main complaints of: reovering from l. mastoid/benign brain tumor, right lower quadrant abdominal and l. eye surgery (wt. put in l. eye m. so upper/lower lids would be functional). Secondary complaints include emotional trauma related to family situation/ pending divorce.
Questioning exam: Questions mainly revolved around post-surgical sx/s. Including: loss of sleep, numbness l. side of face and behind l. mastoid process/ear at incision site. Left side of face muscles do not function: patient can smile and use mouth on the right side but not left side.
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: Pain is in the back of the left knee
Western Diagnosis: Meniscal tear; a ganglion cyst.
Medical History: the patient is a 47-year-old female whose weight is over 200lb. The patient fell down and injured her left knee ten months ago. Soon after the patient started to experience pain in her left knee. MRI reveals meniscal tear and cyst behind the left knee.
Questioning exam: The patient experiences pain in the back of her left knee. It is difficult for her to walk downstairs. The patient could not walk more than five minutes without pain. She also has knee pain when sitting.
Chief Complaint: chronic low back pain
Western Diagnosis: L5/S1 disc herniation s/p laminectomy
Medical History: Patient is 31 yr. old female with two year hx of low back pain as a result of a fall at work 9/99. Diagnosed with L5/S1 disc herniation and radiculopathy at same level. Laminectomy performed 5/00. 14 months later low back, bilateral leg pain and left foot numbness continues.
Questioning exam: Other medical history significant for daily headaches, irregular dizziness, poor appetite, insomnia and bi-polar disorder.
Chief Complaint: Pain in right thumb and wrist
Western Diagnosis: Arthritis
Medical History: Pt. is a 52 yo dental hygienist who presented with painful wrist and thumb that threatened to force her to quit her job. Problem began 9 or 10 years ago and has gotten progressively worse. Her health history is unremarkable, although she had a benign lump removed from her right breast approximately 10 years ago. Her diet is relatively good but she has a great deal of stress due to her aging parents. Sleep and digestion are good.
Chief Complaint: pain and stiffness in both thumbs
Western Diagnosis: osteoarthritis
Medical History: P is 54yr female currently menopausal, @40lbs overweight, has a hx of auto-immune disease in form of psoriatic arthrosis is the lumbar spine. overuse of yoga triggered the disease. Also has minor patches of psoriasis on legs and arms. Diet is rich in dairy, wheat, sugar, salt and wine.
Chief Complaint: Chronic left elbow and knee pain
Western Diagnosis: Left triceps strain and left knee sprain
Medical History: Patient is a 37 year old female with a significant family history of arthritis, alcoholism and diabetes. Patient is married with two children, ages 5 and 2. Patient enjoys a well-balanced diet and would like to resume a regular workout activity. Patient complains of constant pain in left elbow and knee.
Chief Complaint: neck and shoulder pain since 16 years
Medical History: young woman, 35, refugee immigrant from Cuba, married with one daughter; gave history of persistent neck and shoulder pain of 16 yrs duration which came and went and tended to become persistent; worse at end of day, post-stress. works hard at a job and homemaker; non-smoker drinker etc. Indigenous- American diet; obviously overworked; has been to hospitals, has had X rays, medications, to no avail. Heard of our Community Acupuncture Clinic Refugee Component and came for help.