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wk1 Case Study - pain allover for students

Case Study: Chronic Pain
General Info:
Vietnamese, female, 73 years old
Chronic pain all over the body for more than 10 years.
History of current illness:
The patient had chronic pain for more than 10 years. She mentioned the pain was all over the
body, especially on the lower back, knees, and toes. She experienced numbness under her both
feet and tingling in her legs sometimes. She takes Tylenol before goes to bed most of the days.
It makes her easy to fall asleep, however, she still feels pain after taking the medication
Personal Hx:
• She was diagnosed with pre-diabetes and does not take any medications. She said her
blood sugar level has been normal in the past 10 years. However, she didn’t check her blood
sugar very often.
• She was diagnosed with hypertension and takes one medication to control her blood
• Palpitation and chest tightness sometimes
• vision is blurry sometimes
Family medical history:
Sleep: wakes up several times because of pain and urination
Mood: OK
Appetite: OK. Eats a lot of raw food without carbohydrate, no thirst
Digestion: tight, feeling “stuck” and cold
Exercise: no
Bowel movement: once a day and loose
Urination: clear, goes to bathroom 2~3 times per night
Form of the Body: overweight, cold, and wet skin
Complexion: pale, dull
Pulse: first: thin, middle: thin & slippery, third: weak & deep
• Big & puffy, teeth mark
• Thin white coat in the front
• Thick & white coat in the middle and back