Follow Dr Win Huang to Learn Clinical Diagnosis (Case 13)

She Thought It Was a Heart Problem — But It Was a Chest Pressure Evolving from Vomiting

This case is very valuable to me. Not because it is extremely complicated, but because it shows how one problem can develop and change over time, step by step, in a single patient.

The patient is a woman in her 50s. The main reason she came to see me was a very uncomfortable sensation. She described a feeling of pressure behind the sternum, as if something was stuck there and not moving smoothly. This sensation would gradually travel upward to the throat. When it reached the throat, she felt tightness, difficulty breathing, and a sense that the air could not come up properly.

She could not describe it as “pain.” Instead, she said it felt like pressure, tightness, and a pulling or irritating sensation. Each episode usually lasted about 10 minutes, sometimes up to an hour when severe. However, if she stopped and sat down or lay down, the symptoms would gradually settle.

At the beginning, she was treated as a cardiac patient in China. She saw many specialists and had multiple investigations, including ECG, echocardiogram, and exercise stress test. The final conclusion was that there was no clear heart disease. However, the stress test was reported as “suspicious positive,” which made her very anxious. She continued to believe that the problem was related to her heart. Later, she was even referred for psychiatric evaluation and prescribed anti-anxiety medication, but there was no significant improvement.

She came to New Zealand mainly to visit her son, and eventually came to see me.

When I first listened to her symptoms, I did not think it was a cardiac or psychological issue. The location and pattern did not match. So I carefully asked about her history.

All her problems started after a surgery. In 2023, she had a gallbladder removal. Soon after the surgery, she began to experience frequent vomiting. At that stage, she did not have chest pressure or throat tightness. Her main symptom was vomiting.

It was very typical: after eating, especially during an evening walk, if she walked a bit faster, she would feel nauseous and then vomit. The vomit was usually food. If she continued walking after vomiting, she could vomit again. However, if she stayed still and avoided activity, especially during the daytime, she would not vomit.

This pattern lasted for more than half a year.

Later, she learned that walking triggered vomiting, so she reduced her activity or stopped walking altogether. As a result, the vomiting became less frequent. However, the problem did not resolve.

Gradually, her symptoms changed. When she came to see me, vomiting was no longer the main issue. Instead, she developed the current symptoms: pressure behind the sternum, upward movement of discomfort to the throat, throat tightness, and difficulty breathing.

Many clinicians might consider these as two separate problems. But my impression was that this was not two diseases, but one condition changing its presentation over time.

During the consultation, I asked her to walk up and down the stairs a few times. The first two rounds were fine, but by the third or fourth round, her symptoms appeared. She described it clearly: it started as discomfort in the epigastric area, then gradually moved upward to the throat, followed by tightness and difficulty breathing.

On physical examination, I did not find any clear positive signs.

My understanding of her condition was as follows. Initially, after gallbladder removal, she developed repeated vomiting. This repeated vomiting caused continuous mechanical and chemical irritation to the esophagus. Over time, this led to increased sensitivity of the esophagus.

In this sensitized state, the esophagus becomes overly reactive to pressure, movement, and changes in body condition. This can result in symptoms such as chest pressure and a sense of blockage, even without structural obstruction.

In addition, the esophagus is largely controlled by the vagus nerve. Once sensitivity increases, it can easily trigger autonomic nervous system responses. This explains the throat tightness, breathing difficulty, chest discomfort, and even associated neck and upper back symptoms.

If we further consider the tension in the cervicothoracic junction, such as the scalene muscles and thoracic outlet region, these symptoms can be amplified.

So in this case, the problem is not located at a single point. It is a dysfunction of a system. In other words, this is a cross-system regulatory problem.

After explaining this to her, she understood her condition much better.

My treatment approach focused on releasing tension in related regions, including the diaphragm and upper thoracic inlet, and helping the system relax so that breathing and pressure regulation could return toward a more normal state.

After treatment, she immediately felt a difference. She said, “It feels like a heavy burden has been lifted from my shoulders and back, and my head feels clearer.” She then walked on the stairs again and noticed that the pressure was reduced and her breathing felt easier.

This case gave me several important reflections. First, symptoms can change over time. From vomiting to chest pressure to throat tightness, if we only look at one stage, it is easy to misdiagnose. In fact, it is the same problem presenting differently at different stages.

Second, investigations are useful, but only as references. If they do not match the clinical picture, we must return to the patient. The clinician should remain the center of diagnosis.

Third, and more importantly, in cases like this, we are not just treating a single symptom. We are addressing the whole system, especially the autonomic nervous system. In addition, factors such as post-meal activity, movement patterns, and breathing patterns all need to be adjusted. Otherwise, even if the current symptom improves, another form may appear later.

From a traditional Chinese medicine perspective, this patient shows a clear pattern of “Qi rushing upward,” similar to what is described in the Jin Gui Yao Lue as “Ben Tun Qi” rising toward the chest and throat. However, in this case, the origin is not purely emotional disturbance, but rather a functional imbalance of the digestive system that has gradually evolved. It can be understood as a modern, functional-system-based presentation resembling “Ben Tun.”