General situation: Patient Guo Moumou, male, 48 years old, from Zhengzhou, Henan Province, no history of drug and food allergies was found. First visit on December 19, 2019.
Chief complaint: easy to wake up at night for more than 20 days.
History of present illness: 20 days without obvious reason, easy to wake up at night, naco, dry stool, urine. The tongue is dark red, yellow and greasy, and the pulse is wet. Physical examination: BP: 150 mmHg/110 mmHg, 10 years of previous hypertension.
Traditional Chinese medicine diagnosis: insomnia
Syndrome type: hepatobiliary depression syndrome
Treatment: Relieve liver and gallbladder depression, strengthen the spleen, nourish the heart and calm the nerves
Initial Prescription:
2019-01-08 follow-up visit: After taking the medicine, the night sleep is better than before, and the sleep can be adjusted. The tongue is dark red, yellow and greasy, and the pulse is wet.
Processing: 12.19 day plus 20g of night vine. 10 doses of traditional Chinese medicine, one dose per day, decoction and warm serving.
According to the language: Sleeplessness is called "not lying down" and "not blinding" in the "Neijing", which is a type of disease characterized by often not being able to get normal sleep. This disease is mostly caused by emotional injury, uncontrolled diet, work and rest disorders, long-term illness and body weakness and other factors that cause disorders of visceral function, qi and blood imbalance, yin and yang imbalance, and yang does not enter yin and causes the disease. Although there was no obvious cause of the onset of the disease, the patient in this case had a strong body, dry stools, and a dark red tongue with a yellow greasy, and the pathogenesis was considered to be liver depression and fire, phlegm and heat internal disturbance, disturbing the mind and causing sleeplessness. The treatment should relieve the liver and gallbladder depression and heat, strengthen the spleen, nourish the heart and calm the nerves, and add or subtract Dachai Hu Tang. Fangzhong Bupleurum and Skullcap reconcile Shaoyang, Citrus aurantium and wine rhubarb excrete heat knots, peony helps Bupleurum and Skullcap clear the liver and gallbladder depression, Banxia, ginger and stomach inversion, since then on the basis of adding sour jujube kernel to nourish the heart and calm the nerves, Acacia skin to relieve depression and calm the nerves, Poria cocos, cocos to strengthen the spleen and infiltrate dampness, calm the heart and calm the nerves, jujube to nourish Zhongjiao, and burn licorice to reconcile various medicines. During the follow-up visit, the night sleep was better than before, and the night was added to the vine to nourish the heart and calm the nerves.