Initial acc treatment
ACC details
ACC45 No:
Read code:
Date of Accident:
Subjective findings
Reason for visit:
Upper back pain
Previous surgery or fractures:
Nil
Previous illnesses:
Nil
Medication and/or supplements:
not known
Subjective Findings:(patient’s description of injury)
When pulling the lawnmower cord, I sprained my back.
Lifting a heavy box above the head, whilst turning the head, twisted and sprained the neck.
Whiplash to the neck after being hit in the rear by another car
Whilst playing football, I was tripped by another player and fell sideways, straining the knee.
Onset and progression:
Felt sharp pain for one day after the injury, then an ongoing dull ache since then with intermittent sharp pain during certain movements. The shoulder and upper back area feel quite tight.
Aggravated by:
Turn around the neck
Relieved by:
rest
Yellow flags(psychological or emotional factors):
N/A
Red flags(potential serious complications):
N/A
Previous treatment:
physio for 1 session
Objective Findings:
Observation: no swelling, no bruising
Numerical Pain Rating Scale (NPRS): most of the time 5/10, 7/10 at worst
Patient-Specific Functional Scale (PSFS) :
To be able to lift 5kg heavy object 6/10
To be able to sleep on the affected side 6/10
To be able to turn around the neck 6/10
Range of movement:
Extension 55°Flexion 45°
Left
Neck (lateral bending) 35°
Neck (rotation) 70°
Right
Neck (lateral bending) 35°
Neck (rotation) 70°
Diagnosis:
read code(blood stasis and qi Stagnation)
Treatment Principle:
promote Qi and remove blood stasis to relieve the pain
The goal for treatment:
To be able to lift a 5kg heavy object without pain
To be able to sleep on the affected side without pain
To be able to turn around the neck without pain
Treatment Plan:
acupuncture and cupping 1-2times/week
Estimated time frame :
6 weeks/12 weeks
Today’s treatment:
Acupuncture 50 mins
Ashi points in the locally affected area,xiaoshi,hegu,kunlun,yangfu,sanyinjiao
cupping 10mins-in the locally affected area
Post-treatment advice:
Avoid lifting heavy objects.
Keep warm
2nd visit acc treatment
Subjective
Results/Progress:
The patient reports that
The pain has slightly diminished compared to the last visit. However, it worsens after long hours of watching the computer at work. The patient experiences intermittent sharp pain along with a constant dull ache, particularly noticeable during periods of inactivity.
Numerical Pain Rating Scale (NPRS): Most of the time 5/10, 7/10 at worst
Patient-Specific Functional Scale (PSFS):
To be able to lift a 5kg heavy object 6/10
To be able to sleep on the affected side 6/10
To be able to turn around the neck 6/10
Objective
MSK exam
Observation: No swelling, no bruising
tender to touch around the local injured area.
Range of movement:
Extension 55°Flexion 45°
Left
Neck (lateral bending) 35°
Neck (rotation) 70°
Right
Neck (lateral bending) 35°
Neck (rotation) 70°
TCM exam
Tongue: Dark Red Tongue with White Coating
Pulse: Wiry
Plan
Today’s treatment
Acupuncture 50 mins
Ashi points in the locally affected area,xiaoshi,hegu,kunlun,yangfu,sanyinjiao
cupping 10mins-in the locally affected area
Post-treatment advice
Avoid lifting heavy objects.
Keep warm
3rd visit acc treatment
The pain has slightly decreased compared to the last visit but worsens after long hours of using the computer at work. It presents as intermittent sharp pain accompanied by a constant dull ache in the absence of movement. The muscles around the neck feel noticeably tight.tender to touch around the local injured area.
Range of movement:
Extension 55°Flexion 45°
Left
Neck (lateral bending) 35°
Neck (rotation) 70°
Right
Neck (lateral bending) 35°
Neck (rotation) 70°
TCM exam
Tongue: Dark Red Tongue with White Coating
Pulse: Wiry
Plan
Today’s treatment
Acupuncture 50 mins
Ashi points in the locally affected area,xiaoshi,hegu,kunlun,yangfu,sanyinjiao
cupping 10mins-in the locally affected area
Post-treatment advice
Avoid lifting heavy objects.
Keep warm
4th visit acc treatment
Subjective
Results/Progress:
The patient reports that
the pain returned one day after the last treatment, and there is still significant discomfort in the local area. However, the pain is now more localized, presenting as intermittent sensations of pain.
Numerical Pain Rating Scale (NPRS): Most of the time 4/10, 6/10 at worst
Patient-Specific Functional Scale (PSFS):
To be able to lift a 5kg heavy object 7/10
To be able to sleep on the affected side 7/10
To be able to turn around the neck 7/10
Objective
MSK exam
Observation: No swelling, no bruising
tender to touch around the local injured area.
Range of movement:
Extension 55°Flexion 45°
Left
Neck (lateral bending) 35°
Neck (rotation) 70°
Right
Neck (lateral bending) 35°
Neck (rotation) 70°
TCM exam
Tongue: Dark Red Tongue with White Coating
Pulse: Wiry
Plan
Today’s treatment
Acupuncture 50 mins
Ashi points in the locally affected area,xiaoshi,hegu,kunlun,yangfu,sanyinjiao
cupping 10mins-in the locally affected area
Post-treatment advice
Avoid lifting heavy objects.
Keep warm
The pain has slightly decreased compared to the last visit. It comes and goes, worsening after long hours of using the computer at work. The sensation is not sharp but still persists as a constant dull ache. The patient reports feeling much better compared to before.
Numerical Pain Rating Scale (NPRS): Most of the time 3/10, 5/10 at worst
Patient-Specific Functional Scale (PSFS):
To be able to lift a 5kg heavy object 8/10
To be able to sleep on the affected side 8/10
To be able to turn around the neck 9/10
Objective
MSK exam
Observation: No swelling, no bruising
tender to touch around the local injured area.
Range of movement:
Extension 60°Flexion 50°
Left
Neck (lateral bending) 45°
Neck (rotation) 80°
Right
Neck (lateral bending) 45°
Neck (rotation) 80°
TCM exam
Tongue: Dark Red Tongue with White Coating
Pulse: Wiry
Plan
Today’s treatment
Acupuncture 50 mins
Ashi points in the locally affected area,xiaoshi,hegu,kunlun,yangfu,sanyinjiao
cupping 10mins-in the locally affected area
Post-treatment advice
Avoid lifting heavy objects.
Keep warm