General condition: Patient Ma Moumou, male, 56 years old, from Luoyang, Henan Province, did not have a history of drug and food allergies. First visit on 13.03.2019.
Chief complaint: paroxysmal palpitations and chest tightness for 5 days.
History of present illness: the patient had dizziness and increased blood pressure after changing the antihypertensive medication to Jijia 5 days ago, changed to valsartan and amlodipine 3 days ago, the blood pressure control was acceptable, and the heart was upset, Naco, 2 puffs, and sleep. The tongue is pale red, thin and white, and the veins are thin. Physical examination: BP: 142mmHg/90mmHg, previous hypertension, diabetes mellitus for 10 years.
Traditional Chinese medicine diagnosis: chest paralysis and heartache
Syndrome type: Shaoyang syndrome
Treatment: Reconcile Shaoyang, relieve paralysis and relieve pain
Initial Prescription:
2019-03-19 second diagnosis: the patient's upset was relieved compared with before, and he still had dizziness from time to time.
Dispose:
According to the language: The main symptoms of the patient are "palpitations and chest tightness", combined with the tongue, pulse and syndrome, which belongs to the category of "chest paralysis and heartache" in the medicine of the motherland, and the syndrome differentiation is Shaoyang syndrome. Chai Hu plus keel oyster soup is cut from Xiao Chai Hu Tang, Xiao Chai Hu Tang comes from the "Treatise on Typhoid Fever and Miscellaneous Diseases" by the medical saint Zhang Zhongjing, which is a representative prescription for the treatment of Shaoyang syndrome, "cold and heat to the inside, chest and flank bitterness, silent desire to eat, upset and nausea" are the four major signs of Xiao Chai Hu Tang. Fangzhong Bupleurum and Skullcap clear the internal and external heat evil, Banxia, ginger and stomach inversion, Prince's ginseng is beneficial to qi and shengjin, keel and oyster calm the heart, tea tree root strengthens the heart and diuretic, Huixin grass calms the nerves, modern pharmacology research tea tree root, Huixin grass has the effect of strengthening the heart and anti-arrhythmia, and is an important medicine for the treatment of arrhythmia. Salvia, safflower, red peony, sumac wood invigorate blood and dispel blood stasis, the general rule is not painful, citrus aurantium is a wide chest, ginger and jujube take care of stomach qi, cold medicine hurts the stomach, and licorice reconcilies various medicines. The upset was relieved during the follow-up, the patient had high blood pressure for 10 years, and now has pain, "anxious to treat the symptoms" changed to Xiao Chai Hu Tong plus gastrodia, chrysanthemum to suppress liver yang, lotus leaf, grain essence grass, Pueraria lobata to relieve wind and lower blood pressure, modern pharmacological research lotus leaf, grain essence grass, Pueraria lobata can dilate blood vessels, so that the peripheral resistance decreases and thus lowers blood pressure.