Initial acc treatment
ACC details
ACC45 No:
Read code:
Date of Accident:
Subjective findings
Reason for visit:
shoulder 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, with intermittent sharp pain occurring with certain movements.
Aggravated by:
Heavy lifting
Severe pain 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 lift a 5kg heavy object 6/10
To be able to sleep on the affected side 6/10
To be able to place the glass on the shelf at shoulder level 6/10
Range of movement:
Shoulder
Left
Abduction: 140°
Adduction: 20°
Forward flexion: 150°
Extension: 45°
Rotation (test with the elbow flexed to 90 degrees)
External Rotation: 90°
Internal rotation: 70°
Right
Abduction: 140°
Adduction: 20°
Forward flexion: 150°
Extension: 45°
Rotation (test with the elbow flexed to 90 degrees)
External Rotation: 90°
Internal 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 place the glass on the shelf at shoulder level without pain
Treatment Plan:
acupuncture and cupping 1-2times/week
Estimated time frame :
6 weeks/12 weeks
Today’s treatment:
Acupuncture 50 mins
Ashipoints,bafeng,waiguan,tianjing,xiaohai,yangfu,kunlun,neiting
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 has slightly decreased compared to the last visit. However, it worsens after long hours of using the arm at work. The patient experiences intermittent sharp pain along with a constant dull ache, particularly 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 lift a 5kg heavy object 6/10
To be able to sleep on the affected side 6/10
To be able to place the glass on the shelf at shoulder level 6/10
Objective
MSK exam
Observation: No swelling, no bruising
tender to touch around the local injured area.
Range of movement:
Shoulder
Left
Abduction: 140°
Adduction: 20°
Forward flexion: 150°
Extension: 45°
Rotation (test with the elbow flexed to 90 degrees)
External Rotation: 90°
Internal rotation: 70°
Right
Abduction: 140°
Adduction: 20°
Forward flexion: 150°
Extension: 45°
Rotation (test with the elbow flexed to 90 degrees)
External Rotation: 90°
Internal rotation: 70°
TCM exam
Tongue: Dark Red Tongue with White Coating
Pulse: Wiry
Plan
Today’s treatment
Acupuncture 50 mins
Ashipoints,bafeng,waiguan,tianjing,xiaohai,yangfu,kunlun,neiting
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
Still experiencing sharp pain, but the intensity has decreased. Can perform much more flexible movements, and the pain area is more localised.
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 place the glass on the shelf at shoulder level 7/10
Objective
MSK exam
Observation: No swelling, no bruising
tender to touch around the local injured area.
Range of movement:
Shoulder
Left
Abduction: 150°
Adduction: 30°
Forward flexion: 150-180°
Extension: 45-60°
Rotation (test with the elbow flexed to 90 degrees)
External Rotation: 90°
Internal rotation: 70-90°
Right
Abduction: 150°
Adduction: 30°
Forward flexion: 150-180°
Extension: 45-60°
Rotation (test with the elbow flexed to 90 degrees)
External Rotation: 90°
Internal rotation: 70-90°
TCM exam
Tongue: Dark Red Tongue with White Coating
Pulse: Wiry
Plan
Today’s treatment
Acupuncture 50 mins
Ashipoints,bafeng,waiguan,tianjing,xiaohai,yangfu,kunlun,neiting
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 localised, 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 place the glass on the shelf at shoulder level 7/10
Objective
MSK exam
Observation: No swelling, no bruising
tender to touch around the local injured area.
Range of movement:
Left
Abduction: 140°
Adduction: 20°
Forward flexion: 150°
Extension: 45°
Rotation (test with the elbow flexed to 90 degrees)
External Rotation: 90°
Internal rotation: 70°
Right
Abduction: 140°
Adduction: 20°
Forward flexion: 150°
Extension: 45°
Rotation (test with the elbow flexed to 90 degrees)
External Rotation: 90°
Internal rotation: 70°
TCM exam
Tongue: Dark Red Tongue with White Coating
Pulse: Wiry
Plan
Today’s treatment
Acupuncture 50 mins
Ashipoints,bafeng,waiguan,tianjing,xiaohai,yangfu,kunlun,neiting
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 that
Can perform much more flexible movements. The pain is more localised. Still feels a constant dull ache, but the intensity is not as much.
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 8/10
To be able to sleep on the affected side 8/10
To be able to place the glass on the shelf at shoulder level 8/10
Objective
MSK exam
Observation: No swelling, no bruising
tender to touch around the local injured area.
Range of movement:
Shoulder
Left
Abduction: 150°
Adduction: 30°
Forward flexion: 150-180°
Extension: 45-60°
Rotation (test with the elbow flexed to 90 degrees)
External Rotation: 90°
Internal rotation: 70-90°
Right
Abduction: 150°
Adduction: 30°
Forward flexion: 150-180°
Extension: 45-60°
Rotation (test with the elbow flexed to 90 degrees)
External Rotation: 90°
Internal rotation: 70-90°
TCM exam
Tongue: Dark Red Tongue with White Coating
Pulse: Wiry
Plan
Today’s treatment
Acupuncture 50 mins
Ashipoints,bafeng,waiguan,tianjing,xiaohai,yangfu,kunlun,neiting
cupping 10 mins- in the locally affected area
Post-treatment advice
Avoid lifting heavy objects.
Keep warm
About shoulder pain
1.The patient still feels significant pain and is unable to bring their shoulder close to their ear. The pain becomes particularly severe when doing housework. The symptoms include sharp pain along with a constant dull ache.
2.After the last treatment, the patient still feels significant pain and is unable to bring their shoulder close to their ear. The pain becomes particularly severe when doing housework. The symptoms include sharp pain along with a constant dull ache.
3.The pain continues to improve, and there is no longer constant pain. However, when raising the arm to touch the ear, there is still sharp pain, and doing even light housework exacerbates the pain.
4.The pain has become more localized, with less frequent sharp pain. However, it is still quite painful. When not using the arm and at rest, the pain significantly decreases.
5.The pain remains quite significant but has become more localized. The patient feels more flexibility in movement, though there is still sharp pain when bringing the shoulder close to the ear.
6.The patient has been too busy to come in over the past few weeks. The pain has been fluctuating, becoming more localized. There is still sharp pain when raising the shoulder, and sometimes the patient wakes up when the right arm is compressed during sleep.
7.After the last treatment,the patient felt slight relief in symptoms, but there is still sharp pain when raising the arm. The patient cannot lift heavy objects or do housework for extended periods.
8.The pain has been fluctuating. Although it doesn’t feel as severe as the first time, there is still sharp pain when raising the arm. The patient also continues to wake up if the arm is compressed during sleep.
9.The patient can now raise the shoulder, and mobility has slightly improved. However, there is still sharp pain. The patient is unable to do housework for extended periods.
10.The pain is very localized and noticeable. There is still sharp pain when raising the arm, but the patient is fine as long as they don’t lift heavy objects.
11.The pain is very localized. There is a sore pain when lifting slightly heavy objects, and the arm also hurts when raised.
12. There is no pain when the arm is at rest, but lifting objects or raising the arm to touch the ear still causes sharp pain.