Initial acc treatment
ACC details
ACC45 No:
Read code:
Date of Accident:
Subjective findings
Reason for visit:
ankle 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 certain movements.
Aggravated by:
running, standing for 30mins
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 squat 6/10
To be able to run 6/10
To be able to stand for 1 hour 6/10
Range of movement:
ankle
Left
Inversion 30° Eversion 20°
Plantar 40° Dorsal 20°
Right
Inversion 30° Eversion 20°
Plantar 40° Dorsal 20°
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 squat without pain
To be able to run without pain
To be able to stand for 1 hour 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 running
2nd visit acc treatment
Subjective
Results/Progress:
The patient reports that
The pain has slightly decreased compared to the last visit. However, it worsens with long hours of standing 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 squat 6/10
To be able to run 6/10
To be able to stand for 1 hour 6/10
Objective
MSK exam
Observation: No swelling, no bruising
tender to touch around the local injured area.
Range of movement:
ankle
Left
Inversion 30° Eversion 20°
Plantar 40° Dorsal 20°
Right
Inversion 30° Eversion 20°
Plantar 40° Dorsal 20°
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 running
3rd visit acc treatment
Subjective
Results/Progress:
The patient reports that
The pain is more localized. Today, the patient can perform more flexible movements. They still feel a dull ache with occasional sharp pain during certain movements.
Numerical Pain Rating Scale (NPRS): Most of the time 5/10, 7/10 at worst
Patient-Specific Functional Scale (PSFS):
To be able to squat 6/10
To be able to run 6/10
To be able to stand for 1 hour 6/10
Objective
MSK exam
Observation: No swelling, no bruising
tender to touch around the local injured area.
Range of movement:
ankle
Left
Inversion 30° Eversion 20°
Plantar 40° Dorsal 20°
Right
Inversion 30° Eversion 20°
Plantar 40° Dorsal 20°
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 running
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 squat 6/10
To be able to run 6/10
To be able to stand for 1 hour 6/10
Objective
MSK exam
Observation: No swelling, no bruising
tender to touch around the local injured area.
Range of movement:
ankle
Left
Inversion 30° Eversion 20°
Plantar 40° Dorsal 20°
Right
Inversion 30° Eversion 20°
Plantar 40° Dorsal 20°
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 running
5th visit acc treatment
Subjective
Results/Progress:
The patient reports that
The pain is much more localized. There is no more sharp pain, but the patient still feels a dull ache. There is a significant improvement in flexibility of 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 squat 8/10
To be able to run 7/10
To be able to stand for 1 hour 7/10
Objective
MSK exam
Observation: No swelling, no bruising
tender to touch around the local injured area.
Range of movement:
ankle
Left
Inversion 30° Eversion 20°
Plantar 40° Dorsal 20°
Right
Inversion 30° Eversion 20°
Plantar 40° Dorsal 20°
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 running