Initial acc treatment
ACC details
ACC45 No:
Read code:
Date of Accident:
Subjective findings
Reason for visit:
hand 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 after the injury for 1 day, then ongoing dull ache since then with intermittent sharp pain with certain movement.
Aggravated by:
Heavy lifting
Open doors with knob
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 open doors with knob 6/10
To be able to open a jar 6/10
To be able to use fork/spoon 6/10
Range of movement:
Wrist
Left
Radial 15° Ulnar 25°
Extension 55° Flexion 55°
Right
Radial 15° Ulnar 25°
Extension 55° Flexion 55°
palpation:
tender to touch around the local injured area.
Tongue: Dark Red Tongue with White Coating
Pulse: Wiry
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 open doors with knob without pain
To be able to open a jar without pain
To be able to use a fork/spoon without pain
Treatment Plan:
acupuncture and cupping 1-2times/week
Estimated time frame :
6 weeks/12 weeks
Today’s treatment:
Acupuncture 60 mins
Ashipoints around yemen,hegu,wangu
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 hand 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 open doors with knob 6/10
To be able to open a jar 6/10
To be able to use fork/spoon 6/10
Objective
MSK exam
Observation: No swelling, no bruising
tender to touch around the local injured area.
Range of movement:
Wrist
Left
Radial 15° Ulnar 25°
Extension 55° Flexion 55°
Right
Radial 15° Ulnar 25°
Extension 55° Flexion 55°
TCM exam
Tongue: Dark Red Tongue with White Coating
Pulse: Wiry
Plan
Today’s treatment
Acupuncture 60 mins
Ashipoints around yemen,hegu,wangu
Post-treatment advice
Avoid lifting heavy objects.
Keep warm
3rd visit acc treatment
Subjective
Results/Progress:
The patient reports that
The pain is more localized. The patient still feels quite achy, but the intensity is not as much. There is a constant dull ache with occasional intermittent sharp 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 open doors with knob 7/10
To be able to open a jar 7/10
To be able to use fork/spoon 7/10
Objective
MSK exam
Observation: No swelling, no bruising
tender to touch around the local injured area.
Range of movement:
Wrist
Left
Radial 20° Ulnar 30°
Extension 60° Flexion 60°
Right
Radial 20° Ulnar 30°
Extension 60° Flexion 60°
TCM exam
Tongue: Dark Red Tongue with White Coating
Pulse: Wiry
Plan
Today’s treatment
Acupuncture 60 mins
Ashipoints around yemen,hegu,wangu
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 open doors with knob 7/10
To be able to open a jar 7/10
To be able to use fork/spoon 7/10
Objective
MSK exam
Observation: No swelling, no bruising
tender to touch around the local injured area.
Range of movement:
Wrist
Left
Radial 15° Ulnar 25°
Extension 55° Flexion 55°
Right
Radial 15° Ulnar 25°
Extension 55° Flexion 55°
TCM exam
Tongue: Dark Red Tongue with White Coating
Pulse: Wiry
Plan
Today’s treatment
Acupuncture 60 mins
Ashipoints,shaochong,shaoze,zhongchong,taichong,lidui
Post-treatment advice
Avoid lifting heavy objects.
Keep warm
5th visit acc treatment
Subjective
Results/Progress:
The patient reports that
Can perform a full range of movement.
The pain is more localised.
still feels a dull ache
Numerical Pain Rating Scale (NPRS): Most of the time 5/10, 7/10 at worst
Patient-Specific Functional Scale (PSFS):
To be able to open doors with knob 8/10
To be able to open a jar 8/10
To be able to use fork/spoon 8/10
Objective
MSK exam
Observation: No swelling, no bruising
tender to touch around the local injured area.
Range of movement:
Wrist
Left
Radial 20° Ulnar 30°
Extension 60° Flexion 60°
Right
Radial 20° Ulnar 30°
Extension 60° Flexion 60°
TCM exam
Tongue: Dark Red Tongue with White Coating
Pulse: Wiry
Plan
Today’s treatment
Acupuncture 60 mins
Ashipoints around yemen,hegu,wangu
Post-treatment advice
Avoid lifting heavy objects.
Keep warm