Subjective:
- Current Issues: Patient presents with chronic lower back pain persisting for 6 months, exacerbated by prolonged sitting and alleviated by stretching.
- Patient's Description: The patient describes the pain as a dull ache with occasional sharp twinges, rated at 6/10 in severity.
- Progression: Symptoms have gradually worsened over the past two months.
- Impact on Daily Activities: Pain limits the patient's ability to perform daily tasks and affects work productivity.
- Emotional State: The patient reports feeling stressed and anxious due to the persistent pain.
- Lifestyle Factors: The patient follows a sedentary lifestyle with irregular exercise and poor sleep patterns.
- Treatment History: Previous acupuncture sessions provided temporary relief.
Past Medical History:
- The patient has a history of lumbar disc herniation diagnosed two years ago.
- Social History: Works a desk job with long hours.
Objective:
- Physical Examination: Pulse is wiry and rapid; tongue is pale with a thin white coating.
- Vital Signs: BP 120/80, HR 72, Temp 98.6°F.
Assessment:
- Problem List: Chronic lower back pain.
- Diagnosis: Kidney Qi deficiency with blood stasis.
- Principles of Treatment: Tonify Kidney Qi and invigorate blood.
Plan:
- Treatment Plan: Acupuncture points used include BL23, BL25, and GV3 with moxibustion to warm the channels and alleviate pain.
- Additional Modalities: Cupping therapy applied to the lower back.
- Lifestyle Recommendations: Encourage regular stretching exercises and stress management techniques such as meditation.
Additional Notes:
- Follow-Up: Schedule next appointment in one week to assess progress and adjust treatment as necessary.
Subjective:
- [current issues, reasons for visit, and history of presenting complaints] (include only if explicitly mentioned)
- Patient's Description: [details of the patient's experience, symptoms, and concerns] (include only if explicitly mentioned)
- [chief complaints such as requests, symptoms, and their context (e.g., duration, timing, location, quality, severity)] (include only if explicitly mentioned)
- [factors that worsen or alleviate symptoms, including self-treatment attempts and effectiveness] (include only if explicitly mentioned)
- Progression: [how symptoms have changed or evolved over time] (include only if explicitly mentioned)
- Previous Episodes: [any past occurrences of similar symptoms, their management, and outcomes] (include only if explicitly mentioned)
- Impact on Daily Activities: [how symptoms affect daily life, work, and activities] (include only if explicitly mentioned)
- Associated Symptoms: [any additional focal or systemic symptoms accompanying chief complaints] (include only if explicitly mentioned)
- Emotional State: [patient's emotional condition and stress levels] (include only if applicable)
- Lifestyle Factors: [diet, exercise, sleep patterns] (include only if applicable)
- Treatment History: [previous acupuncture treatments and outcomes] (include only if applicable)
Past Medical History:
- [details of past medical history, including medications, medical diagnosis, and conditions] (include only if explicitly mentioned)
- [contributing factors such as past medical/surgical history relevant to the current visit] (include only if explicitly mentioned)
- [social history relevant to the chief complaints] (include only if explicitly mentioned)
- [family history relevant to the chief complaints] (include only if explicitly mentioned)
- [exposure history] (include only if explicitly mentioned)
- [immunization history and status] (include only if explicitly mentioned)
- [any other relevant subjective information] (include only if explicitly mentioned)
Objective:
- Physical Examination: [findings from physical assessment, including pulse diagnosis and tongue observation] (include only if explicitly mentioned)
- Vital Signs: [BP, HR, Temp, and other relevant measures] (include only if explicitly mentioned)
Assessment:
- [list issues, problems, or requests by name] (include only if explicitly mentioned)
- [assessment or diagnosis related to identified issues] (include only if explicitly mentioned)
- Problem List: [identified issues to be addressed] (include only if explicitly mentioned)
- Diagnosis: [TCM diagnosis and differentiation] (include only if explicitly mentioned)
- Principles of Treatment: [TCM principles of treatment] (include only if explicitly mentioned)
Plan:
- [treatment planned for each identified issue, including rationale] (include only if explicitly mentioned)
- [treatment plan with acupuncture points used, technique, and rationale] (include only if explicitly mentioned)
- [additional treatment modalities like E-stim, cupping, gua sha, tui na] (include only if explicitly mentioned)
- Lifestyle Recommendations: [dietary advice, exercise, stress management techniques] (include only if explicitly mentioned)
Additional Notes:
- [relevant referrals for identified issues] (include only if explicitly mentioned)
- Follow-Up: [next appointment scheduling and goals for the next session] (include only if explicitly mentioned)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned, leave the relevant placeholder or section blank.)
