General condition: Patient Wang Moumou, female, 55 years old, from Zhengzhou City, Henan Province, allergy history: not found. First visit2018-10-12.
Chief complaint: paroxysmal palpitations for 10 days.
History of present illness: the patient had palpitations after exertion 10 days ago, which lasted for a few minutes, relieved after taking fast-acting Xingxin pills, and intermittently appeared transient palpitations in the past 10 days, lasting 2-5 minutes, with occasional vague pain in the precordial area, no obvious stenosis in the coronary artery of CAG, poor food intake, poor sleep, dreaminess, acceptable urination, poor stool discharge, and small amount. Previous history of erosive gastritis for 5 months. BP：110 / 76mmHg。 The tongue is red, yellow and greasy, and the pulse is thin.
Traditional Chinese medicine diagnosis: palpitations
Syndrome type: phlegm-heat internal disturbance syndrome
Treatment: clear away heat and phlegm, calm the heart and palpitations
Initial Prescription:
2018-10-23Follow-up visit: palpitations, stomach discomfort, physical fatigue, poor mental state, Naco, poor sleep, dreams, and two stools after taking the medicine. The tongue is red, the moss is thin and white, and the pulse is heavy and thin.
TCM diagnosis: palpitations (Shaoyang syndrome)
Dispose:
2018-11-13Third diagnosis: after taking the drug, the symptoms are reduced, the fatigue is reduced, the mental state is improved, the waist is dull pain, the sleep can be done, and the two stools are adjusted. The tongue is red, thin and white, and the veins are thin.
Treatment: Guarding the top, change the tea tree root to 60g, add 30g of gynostemma and 30g of lotus leaves.
According to the language: the patient middle-aged and elderly women, with "paroxysmal palpitations" as the main complaint, belongs to the category of "palpitations" in traditional Chinese medicine, combined with the tongue pulse (red tongue, yellow greasy) syndrome differentiation for phlegm heat internal disturbance syndrome, the addition or subtraction of Coptis Wen bile decoction, but the second diagnosis of yellow greasy moss faded, but there are still palpitation symptoms, the overall efficacy is not good, so the second diagnosis combined with the tongue and vein, changed to less yang syndrome, the party selected Bupleurum plus keel oyster soup, the third diagnosis complained that the palpitation symptoms were significantly reduced, and the effect was satisfactory. Throughout this case, the patient's middle-aged and elderly women, consciously felt palpitations in their hearts, four diagnoses and references, a hot image, but the effect of giving Huanglian warm bile decoction to clear heat, dryness and dampness and phlegm is not good, I am afraid that the root of the disease is unfavorable in Shaoyang cardinal, yang evil is trapped, the liver and gallbladder meridian qi are unfavorable, the bile is hot and depressed, then the chest is full and annoying, the gallbladder is inflamed, the stomach is hot and steaming, and the heart is disturbed and palpitations. Treat the liver, reconcile Shaoyang, calm the heart and calm the nerves; Fang Xuan Bupleurum plus keel oyster soup (Bupleurum, Banxia, ginseng, keel, oyster, cinnamon branch, rhubarb, Poria cocos, ginger, jujube, lead dan) plus or minus. Bupleurum and skullcap soothe the liver and clear heat, and the combination of firewood and qin can be used to achieve qi depression and fire depression, which is the main medicine in the formula; Semi-summer dryness and dampness dissolve phlegm; ginger and jujube reconcile the spleen and stomach; Pseudostellaria ginseng, Poria cocos, and Poria cocos invigorate qi and strengthen the spleen, cultivate soil and inhibit wood; Guizhi warms the heart and stops palpitations; Keels and oysters are subdued by the sun, and the heart is restrained and calmed; The patient has a history of erosive gastritis in the past, complains of gastric discomfort, and adds sand to regulate qi and stomach; Zhuru clears phlegm and heat; Tea tree root and huixin grass can calm the mind and have anti-arrhythmic effects. The combination of all medicines plays a role in reconciling the cardinal, clearing the liver and gallbladder depression and heat, and calming the heart and nerves. At the third diagnosis, the palpitations were significantly reduced, and the curative effect was satisfactory.