Case Study：Neck Back to Chest Pain

Patient: Ms. Wu，female，age 61

Date of first appointment: July 7th, 2022

Chief complaints：neck, back pain that goes to the chest. Limited neck mobility.

Tongue diagnose：pale and fat tongue, thick and white coating, clear teeth marks.

TCM syndrome differentiation：qi and blood deficiency, cold and dampness blocking the channels

TCM diagnosis：1. cold and dampness type Bi Zheng (obstruction syndrome)，2. Xiong Bi (thoracic obstruction)

Treatment Principles：Tonify and Invigorate blood，expel cold and dampness, clear and activate channels

TCM formula：Chuan Shan Long 10g, Ge Gen 10g, Ci Diao Gen 10g, Ji Xue Tang 20g, Dan Shen 10g, Ze Lan 10g, Chi Shan 10g, Fu Ling 10g, Gui Zhi 10g, Pei Lan 10g, Hu Zhang 10g, Sang Zhi 10g

7/27/2022 follow up: After 5 doses of the TCM formula, patient no longer have pain in the neck, back and chest region. Her neck mobility has been restored.

Past history: In 2016, patient had severe venous thrombosis, which caused swelling and pain in the right lower limb. Patient was unable to walk for half a year. After taking Buzhong Yiqi Decoction, in which the amount of astragalus was increased to 80 grams, with 10 grams of Changbai Mountain Wild Ginseng, and with 10 grams of Salvia miltiorrhiza added to the formula, for 6 months, the patient no longer had any symptoms.

Case analysis:

The reason for the patient’s conditions is the overexertion of the upper extremities, coupled with emotional stress. Her father-in-law passed away two weeks before the onset of the disease. The patient was overwhelmed with work to prepare for the funeral, taking care of family and lack of sleep. This leads to the deficiency of qi and blood, obstruction of channels due to cold and dampness, stagnation of qi and blood stasis, which cause pain in neck, shoulders, upper limbs, and limited upper body movement, combined with pain in the back and front chest.

The principle of treatment and prescription, analysis of disease is to identify the main issues, which in this case is blood deficiency, cold and dampness, qi stagnation and blood stasis. The treatment principle is to treat both root causes and symptoms at the same time. Meanwhile, psychological counseling is very important in Taoist medicine. This helped the patient realize the causes of her symptoms is overwork and emotional stress. She must let go of the busy housework, set aside time for herself to relax to achieve a better work and rest balance. The doctor should teach the patients the ancient Chinese medicine concept of accepting, letting go, being present, and 30% treatment and 70% maintenance, so as to stimulate the self-healing potential of patients. The best doctor is the patient themselves. Also, to prevent the symptoms from recurring, the patient should practice Tai Chi and Zhan Zhuang.