| Subjective | Example |
| Results/Progress | Less pain(measure)on wb. decreased swelling(measure). decreased swelling(measure).increased dorsiflexion (measure). Tolerated well does not describe how effective a treatment is. Decreased pain in the affected area(3-5/10) Physio: Feels as though there has been an improvement in her pain whilst walking. able to walk around 15mins prior to the onset of some pain.Not as swollen and not as stiff in the morning. |
| Objective | |
| examination | Physio: Knee to wall L=2cm,R=4cm. Swelling measured around malleoli L=20cm,R=22cm. Single leg balance eyes open L 40secs,R 20secs. Hop L full and pain free, R=full with pain on landing 4/10 |
| Observation | No swelling, no bruising tender to touch in the locally affected area. Walk with limping gait, back supported with both hands->normal gait Walking with the crutch on the left->can walk without the crutch Difficult to lie on the back->better to lie on the back today Spasm in the left side of back muscle,-> feel less spasm in frequency Reduced lumbar flexion and side bending to left-> increased lumber flexion and side bending No reddish No scarMild bruising ->less bruised Swelling grade2 in the affected area-> less swollen Range of motion（各大关节具体活动度数总结）:https://naturaltherapysupplies.co.nz/?product=range-of-movement |
| TCM exam | Tongue: Dark Red Tongue with White CoatingPulse: Wiry |
| Diagnosis | S572(N/A) Lumber Sprain (qi stagnation&blood stasis in Bladder Meridian) |
| Treatment Principle | promote Qi and remove blood stasis to relieve the pain |
| Today’s treatment | Example: 1)acupuncture 45mins – weizhong(L,R)-,chengshan(L,R),taixi(L,R)+Cupping -shenshu(L,R)10mins+Tuina in local 5mins 2) BL40(L),BL57(R),KI3(R,L)+Cupping -BL23(L,R)10mins+Tuina in local 5mins 3) Master tong’s points-Shou jie,Wan shun 4) Ashipoints around the Chize area based on Tan’s balance method theory Other treatment 5) Heat Lamp 45mins during the acupuncture treatment 6) Apply a heat pack or warm compress to the affected area for 15 minutes after acupuncture treatment to promote local circulation and relaxation. |
| Post-treatment advice | 【simplified template】 Avoid lifting heavy objects keep the affected area warm 【detailed Template】 1. Encourage the application of ice packs for 30 minutes every 3 hours every day to reduce inflammation. 2. Suggest applying heat packs for 15 minutes after activities that may cause increased pain. 3. Recommend a gentle range of motion exercises to prevent stiffness. 4. Encourage the patient to continue performing the prescribed range of motion exercises to maintain and improve lower back mobility. 5. Provide instructions for proper self-care and home management of the condition. 6. Instruct the patient to avoid strenuous activities that aggravate the pain, apply ice packs for 30 minutes several times a day, and perform a gentle range of motion exercises to prevent stiffness. 7. Advise the patient to monitor any changes in symptoms and report any new developments or concerns during the following days. Others: The importance of rest and careful movement has been emphasised to avoid exacerbation of the injury. We will monitor the patient’s progress closely over the coming weeks and adjust the treatment plan as necessary. Follow up: 1. The patient is scheduled for her next appointment at the same time next week. The treatment efficacy and any changes in the patient’s condition will be evaluated during each visit. 2. The patient will return in two days for her next session. Regular reassessment of her pain levels sleep quality, and ROM will be conducted to monitor progress and adjust the treatment plan accordingly. 3. Schedule the patient for a follow-up appointment in one week to reassess the progress, modify the treatment plan if necessary, and evaluate the effectiveness of the acupuncture intervention. Review 1/52（约下一周）Go to the GP if getting worse |
