頸椎痛 Neck Pain

頸椎痛Neck Pain

案例

姓名name:XXXX 

性別sex:女F

年齡age:36

/婚姻marital status:未婚Single

職業occupation: 會計 accountant

現病史 (Present i11ness):

脖子僵硬 疼痛 左右旋轉不利 一周 

She complained that her neck was pain and stiffness.

It’s hard to turn around her head for one week.

望診Looking Examination:

舌紅苔白 舌下絡脈瘀阻

Red tongue white coating 

Sublingual collaterals Stagnation

問診Asking Examination:

二便正常 不易入睡 食慾尚可

Normal bowl movement and urination

Good appetite but hard to fall into sleep

觸診Touching Examination:

弦脈 斜方肌緊繃

Wiry pulse and muscle tension in trapezius

中醫診斷TCM Diagnosis 

血瘀型頸椎痛 neck pain with blood stasis

治療原則Treatment principles:

活血化瘀boost blood circulation

中藥處方:

桂枝湯gui zhi tang6g

合歡皮he huan pi3g 

葛根ge gen3g 

川芎cuan quong1g 

地龍di long1g

4*5天 

三餐飯後及睡前服用

To take 4 times a day after meal and before sleep.

二週追蹤follow up after 2 weeks: 

治療後痊癒未再復發 

recovered.