Neck and right shoulder pain for 2 days

Date of first visit : 14/8/09 Gender : F

Age : 19

Chief complaint : Neck and right shoulder pain for 2 days.

Description :

A. Asking

The patient has suffered from neck and right shoulder pain for 2days. When she does not move, pain is dull but when she moves her shoulder, pain is sharp.

She thinks a reason of pain is bad sleeping position 2days ago. There are no radiating pain, and she does not know what makes it worse or batter.

She hasn't got any injury about shoulder, and she did not use her shoulder too much. She does not feel any pain when I press the shoulder and neck.

No chill and no fever, no headache, no dizziness, good appetite, good sleeping, no dream, normal urination and defecation, no thirsty, no dry mouth, prefer to drink cold water.

Past history : NAD

Lifestyle : 1 soju(眞露)/days, 10 pieces/1 day, stressful life.

Menstruation, Martial & obstetrical history : 13 7/29, serious pain before and during period.

B. Inspection

General : red cheeks

Others : NAD

Tongue : greasy, thin white coating, pink tongue.

C. Auscultation/Olfaction

Sound : NAD

Odours : NAD

D. Palpation

Body ares : NAD

Pulse : slippery

Case summary

Diagnosis : Neck and right shoulder pain.

Syndrome : Qi and blood statgnation

Treatment principle : remove qi and blood stagnation

Point : Tian zhong, bing feng, ashi point.

Explanation : Since she got this problem, there was no injury or over use of shoulder, just the temperature was so cold, and she slept with bad position, those two thing made qi and blood stagnation on local area.

Bing feng, Tian zhong, ashi point : local point for promoting qi and blood stagnation on local area to relieve pain.

Definition

Shoulder pain involves any pain in or around the shoulder joint.

WMS

Alternative Names

Pain - shoulder

Considerations

The shoulder is the most mobile joint in the human body. The rotator cuff in the shoulder is made up of four tendons. These tendons give the shoulder a wide range of motion.

Any swelling, inflammation, tearing, or bony changes around these tendons causes pain when a person tries to move the arm above the head, behind the back, or straight out in front.

Common Causes

The tendons pass underneath a rigid bony arch in the shoulder. The most common cause of shoulder pain is when the tendons become trapped under this arch. The compressed tendons become inflamed or damaged, a condition called rotator cuff tendinitis. This can occur from general wear and tear as you get older, an activity that requires constant shoulder use like baseball pitching, or an injury.

TCM

The shoulder pain can be caused by obstruction of wind, cold, dampness, phlegm, or qi and blood stagnation. Deficiency of LV and KD, deficiency of Qi and blood, or Qi and blood stagnation can also be the reason of shoulder pain.

The main symptoms are inability to move, such as feel pain when doing back ward rotating, sever pain at night.

There are 4 stages to get recover. Firstly pain in getting sever, secondly pain get reduced but muscle get harder(contract), third, pain all gone but mescle still get contracted, and fourth, muscle get recover and problem all gone.

If the patient have treatment, problem wii gone within 8 months, but if not, it will take 1~2years.

Case conclusion

I treated this patient just once and next day morning, pain was gone. May be the problem is just 2days, short time, so treatment was very effective, I think. Actually I prepared lifestyle advice for her when I get home, but when I woke up in the next morning and she text me she got recover. So I did not put my life style advice in here because lifestyle advice was useless for the patient.