Initial acc treatment
ACC details
ACC45 No:
Read code:
Date of Accident:
Subjective findings
Reason for visit:
Toe 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:
Walking
Jumping
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 kickball 6/10
To be able to run 6/10
To be able to stand for 1 hour 6/10
Range of movement:
left
extension 70°
flexion 45°
right
extension 70°
flexion 45°
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 kickball 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 around the local area,zulinqi,neiting,taibai,taichong,sanyinjiao
cupping 10 mins- in the locally affected area
Post-treatment advice:
Avoid too much running
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 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 kickball 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:
extension 70°
flexion 45°
TCM exam
Tongue: Dark Red Tongue with White Coating
Pulse: Wiry
Plan
Today’s treatment
Acupuncture 50 mins
Ashipoints around the local area,zulinqi,neiting,taibai,taichong,sanyinjiao
cupping 10 mins- in the locally affected area
Post-treatment advice
Avoid too much running
Keep warm
3rd visit acc treatment
Subjective
Results/Progress:
The patient reports that
The pain is more localized compared to the first visit. The patient still feels sore when walking, 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 kick ball 7/10
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:
extension 70°
flexion 45°
TCM exam
Tongue: Dark Red Tongue with White Coating
Pulse: Wiry
Plan
Today’s treatment
Acupuncture 50 mins
Ashipoints around the local area,zulinqi,neiting,taibai,taichong,sanyinjiao
cupping 10 mins- in the locally affected area
Post-treatment advice
Avoid too much running.
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 kickball 7/10
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:
extension 70°
flexion 45°
TCM exam
Tongue: Dark Red Tongue with White Coating
Pulse: Wiry
Plan
Today’s treatment
Acupuncture 50 mins
Ashipoints around the local area,zulinqi,neiting,taibai,taichong,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 that
Experiencing a constant dull ache with occasional sharp pain during specific movements. The pain is now quite localised.
Numerical Pain Rating Scale (NPRS): Most of the time 5/10, 7/10 at worst
Patient-Specific Functional Scale (PSFS):
To be able to kickball 8/10
To be able to run 8/10
To be able to stand for 1 hour 8/10
Objective
MSK exam
Observation: No swelling, no bruising
tender to touch around the local injured area.
Range of movement:
extension 70°
flexion 45°
TCM exam
Tongue: Dark Red Tongue with White Coating
Pulse: Wiry
Plan
Today’s treatment
Acupuncture 50 mins
Ashipoints around the local area,zulinqi,neiting,taibai,taichong,sanyinjiao
cupping 10 mins- in the locally affected area
Post-treatment advice
Avoid too much running.
Keep warm