9.Head 头 – Tcm Foundation

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Initial acc treatment
ACC details
ACC45 No:
Read code:
Date of Accident:

Subjective findings
Reason for visit:
Headache
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 my 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 specific movements.

Aggravated by:
Turn around the neck and head
Relieved by:
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 5kg heavy object 6/10
To be able to sleep on the affected side 6/10
To be able to turn around the neck 6/10

Range of movement:
Extension 55°Flexion 45°
Left
Neck (lateral bending) 35°
Neck (rotation) 70°
Right
Neck (lateral bending) 35°
Neck (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 5kg heavy object without pain
To be able to sleep on the affected side without pain
To be able to turn around the neck without pain
Treatment Plan:
acupuncture and cupping 1-2times/week
Estimated time frame :
6 weeks/12 weeks
Today’s treatment:
Acupuncture 60 mins
Ashipoints,shaochong,shaoze,zhongchong,taichong,lidui
Post-treatment advice:
Avoid lifting heavy objects.
Keep warm

2nd visit acc treatment

The pain is slightly decreased compared to the last visit. However, it worsens after long hours of using the computer at work. Experiencing intermittent sharp pain with a constant dull ache when not in motion. Also reports occasional episodes of easily confused memory.

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 5kg heavy object 6/10
To be able to sleep on the affected side 6/10
To be able to turn around the neck 6/10

Objective
MSK exam
Observation: No swelling, no bruising

tender to touch around the local injured area.

Range of movement:
Extension 55°Flexion 45°
Left
Neck (lateral bending) 35°
Neck (rotation) 70°
Right
Neck (lateral bending) 35°
Neck (rotation) 70°

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

3rd visit acc treatment

Subjective
Results/Progress:
The patient reports that
The pain has slightly diminished compared to the last visit. However, it intensifies after long hours of using the computer at work. The pain presents as intermittent sharp pain with a constant dull ache in the absence of movement. The muscles around the neck feel notably tight.
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 5kg heavy object 7/10
To be able to sleep on the affected side 7/10
To be able to turn around the neck 7/10

Objective
MSK exam
Observation: No swelling, no bruising

tender to touch around the local injured area.

Range of movement:
Extension 55°Flexion 45°
Left
Neck (lateral bending) 35°
Neck (rotation) 70°
Right
Neck (lateral bending) 35°
Neck (rotation) 70°

4th visit ACC treatment

Subjective
Results/Progress:
The patient reports that
The pain returned one day after the last treatment, and it continues to be quite intense in the local area. However, the pain is now more localised and presents as intermittent discomfort.
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 5kg heavy object 7/10
To be able to sleep on the affected side 7/10
To be able to turn around the neck 7/10

Objective
MSK exam
Observation: No swelling, no bruising

tender to touch around the local injured area.

Range of movement:
Extension 55°Flexion 45°
Left
Neck (lateral bending) 35°
Neck (rotation) 70°
Right
Neck (lateral bending) 35°
Neck (rotation) 70°

5th visit acc treatment
Subjective
Results/Progress:
The patient reports that
The pain has slightly decreased compared to the last visit. It comes and goes, worsening after long hours of using the computer at work. The sensation is not sharp but remains a constant dull ache. Overall, there is a significant improvement compared to before.

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 5kg heavy object 8/10
To be able to sleep on the affected side 8/10
To be able to turn around the neck 9/10

Objective
MSK exam
Observation: No swelling, no bruising

tender to touch around the local injured area.

Range of movement:
Extension 60°Flexion 50°
Left
Neck (lateral bending) 45°
Neck (rotation) 80°
Right
Neck (lateral bending) 45°
Neck (rotation) 80°