General condition:Guan XX, male, 62 years old, employee, Shanxi Changzhi people. No history of drug allergy was found. First visit on June 1, 2018.
Complaint: Intermittent head and eye swelling, double vision for 1 month.
History of present illness: Head and eye swelling for no apparent reason, increased secretions in both eyes, accompanied by 1 month ago Persistent double vision (strabismus), decreased visual acuity, no obvious abnormalities were found in cranial CT, blood sugar, and fundus examination. Acupuncture, physiotherapy, and decoction treatment had poor results for half a month. Red tongue, yellow greasy coating, thin pulse.
Traditional Chinese Medicine Diagnosis:Vertigo
Syndrome: Hepatobiliary Depression and Heat Syndrome
Treatment: span>Shugan Qingre
Preliminary prescriptions:
2018 Second visit on March 15: The symptoms were relieved after taking the medicine, and there was still vertigo , Blurred vision, occasional cough, expectoration, white phlegm, stiffness in the back of the neck, sleeplessness, and bowel movements. Red tongue, yellow and greasy coating, and thin pulse.
Processing:6month< /span>1Japanese Radix Salviae Miltiorrhiza24g, plus kudzu root30g, Ligustrum lucidum15g, Tribulus terrestris15g. Traditional Chinese medicine 15paid, one dose per day, decoct in water.
Note:Dizziness and bloating in this case , dizziness, combined with tongue and pulse, Wang Shi’s syndrome differentiation is liver and gallbladder stagnation and heat. “Su Wen·Zhizhen Yao Da Lun” says:“All winds that dispel dizziness belong to the liver”. Liver and gallbladder stagnation and heat will lead to the imbalance of qi in the human body, and the liver is the viscera of wind wood. Master Wang used Dachaihu Decoction to dispel wind and calm the liver, clear the internal organs and relieve heat, and add Prunella vulgaris, chrysanthemum, and Gujingcao to clear liver and improve eyesight; Panax notoginseng clears heat and calms liver; Zhuru clears heat and resolves phlegm; Ginger jujube grass strengthens spleen and harmony In the middle, licorice can also reconcile various medicines; add salvia to activate blood and remove blood stasis, so that the metabolism of qi, blood and water is balanced, yin and yang are secreted, and the effect is like a drum. Although the symptoms have been alleviated in the second diagnosis, the vision is still unclear and the back of the neck is stiff. Therefore, Pueraria japonica is added to relieve muscle and dredging collaterals, Ligustrum lucidum nourishes the liver and kidney, and Tribulus terrestris calms the liver and improves eyesight.