Initial acc treatment
ACC details
ACC45 No:
Read code:
Date of Accident:
Subjective findings
Reason for visit:
Lower 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, followed by an ongoing dull ache since then, experiencing intermittent sharp pain with specific movements. Feels quite uncomfortable with any sort of movement.
Aggravated by:
Heavy lifting
pain 5-7/10 if carrying any weight
Relieved by:
heat pack/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 bend over to put on socks or shoes 6/10
To be able to lift a 5kg heavy object 6/10
To be able to get out of a car 6/10
Range of movement:
Back
Extension 20° Flexion 70°
Left
Lateral (flexion) 20°
Right
Lateral (flexion) 20°
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 bend over to put on socks or shoes without pain
To be able to lift a 5kg heavy object without pain
To be able to get out of a car 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,taixi,fuliu,shenshu,guanyuanshu,sanyinjiao
cupping 10 mins- 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 is slightly decreased compared to the last visit. However, it worsens after long hours of standing at work. The pain is characterized by intermittent sharp sensations along with a constant dull ache, especially noticeable without movement.
Numerical Pain Rating Scale (NPRS): Most of the time 5/10, 7/10 at worst
Patient-Specific Functional Scale (PSFS):
To be able to bend over to put on socks or shoes 6/10
To be able to lift a 5kg heavy object 6/10
To be able to get out of a car 6/10
Objective
MSK exam
Observation: No swelling, no bruising
tender to touch around the local injured area.
Range of movement:
Back
Extension 20° Flexion 70°
Left
Lateral (flexion) 20°
Right
Lateral (flexion) 20°
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,taixi,fuliu,shenshu,guanyuanshu,sanyinjiao
cupping 10 mins- in the locally affected area
Post-treatment advice
Avoid lifting heavy objects.
Keep warm
3rd visit acc treatment
Subjective
Results/Progress:
The patient reports that
the pain is slightly reduced compared to the last visit but worsens after long hours of using the arm at work. The pain is characterized by intermittent sharp sensations along with a constant dull ache, especially noticeable without movement. The patient still feels quite sore but notes an improvement compared to the first visit.
Numerical Pain Rating Scale (NPRS): Most of the time 4/10, 6/10 at worst
Patient-Specific Functional Scale (PSFS):
To be able to bend over to put on socks or shoes 7/10
To be able to lift a 5kg heavy object 7/10
To be able to get out of a car 6/10
Objective
MSK exam
Observation: No swelling, no bruising
tender to touch around the locally affected area.
Range of movement:
Back
Extension 25° Flexion 80°
Left
Lateral (flexion) 25°
Right
Lateral (flexion) 25°
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,taixi,fuliu,shenshu,guanyuanshu,sanyinjiao
cupping 10 mins- 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 bend over to put on socks or shoes 7/10
To be able to lift a 5kg heavy object 7/10
To be able to get out of a car 6/10
Objective
MSK exam
Observation: No swelling, no bruising
tender to touch around the locally affected area.
Range of movement:
Back
Extension 25° Flexion 80°
Left
Lateral (flexion) 25°
Right
Lateral (flexion) 25°
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,taixi,fuliu,shenshu,guanyuanshu,sanyinjiao
cupping 10 mins- in the locally affected area
Post-treatment advice
Avoid lifting heavy objects.
Keep warm
5th visit acc treatment
Subjective
Results/Progress:
The patient reports feeling much more flexible in movement but still experiences occasional sharp pain. The frequency of pain has decreased, and there is a constant dull ache when bending over the back.
Numerical Pain Rating Scale (NPRS): Most of the time 3/10, 5/10 at worst
Patient-Specific Functional Scale (PSFS):
To be able to bend over to put on socks or shoes 8/10
To be able to lift a 5kg heavy object 8/10
To be able to get out of a car 8/10
Objective
MSK exam
Observation: No swelling, no bruising
tender to touch around the locally affected area.
Range of movement:
Back
Extension 25° Flexion 90°
Left
Lateral (flexion) 25°
Right
Lateral (flexion) 25°
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,taixi,fuliu,shenshu,guanyuanshu,sanyinjiao
cupping 10 mins- in the locally affected area
Post-treatment advice
Avoid lifting heavy objects.
Keep warm