General:HuXX, female, 64 years old, unemployed, from Handan, Hebei. No history of drug allergy was found. 2018year07month13day.
Complaint:proteinuria detected2days.
History of present illness:2 During the physical examination a few days ago, it was found that the urine protein was increased, and there was no obvious discomfort. Usually, the urine was frequent and heavy, and nocturia was 4-5 times. Urine routine: occult blood 2+, protein+-, white blood cells+-, normal Elevated blood pressure, controlled at 132/65mmHg; now taking nifedipine tablets, statin, aspirin, sometimes dizziness, sodium carbamide, poor sleep, difficulty falling asleep, easy Surprised, bowel movements are normal. Red tongue, thin white fur, and thin pulse. Previous hypertension5years, hyperlipidemia2years.
Traditional Chinese Medicine Diagnosis:Vertigo p>
Syndromes:Liver and Kidney Deficiency Syndrome
Treatment:Nourishing the liver and kidney, calming the liver and suppressing the yang
Preliminary prescriptions:
< p>201807month24daySecond Clinic:Dizziness improved after taking the medicine, nausea after taking the medicine, Normal sleep, yellow urine, normal stool. Red tongue, thin white fur, thin pulse.
Processing:7< span>month13Japanese mulberry leaves changed to 50g, plus plantain30g, Talc30g, Licorice6g. Chinese herbal formula granules9paid, one dose a day, taken with water.
Notes:The main symptom of the patient is dizziness , According to the red tongue, thin white coating, deep and thin pulse, and the combination of four diagnoses, it can be diagnosed as “dizziness” in traditional Chinese medicine. The treatment is based on nourishing liver and kidney, calming liver and subduing yang. When the patient is over 500 years old, the yin of the liver and the kidney is gradually deficient, and the deficiency of the yin of the kidney cannot nourish the liver wood, resulting in a deficiency of the yin of the liver and the yin of the liver and the kidney. Excessive use of yang, excessive emotion, stagnation of liver qi, stagnation of qi transforming into fire, dark consumption of liver yin, rising movement of wind and yang, disturbance of the upper part of the body, dizziness and other symptoms. Chinese medicine believes that hematuria is closely related to the three meridians of the heart, liver and kidney. “Medical Heart Enlightenment” Volume 3: “Heart governs blood, and heart qi is hot, then retains heat in the bladder, and yin and blood move recklessly and drowns out. The liver also controls stagnation, and the liver fire is full, which also causes blood in the urine.” “The source of miscellaneous diseases” Candle·Five strangulations and two turbidity sources”: “hematuria, drowning orifice disease. The cause is due to kidney deficiency.” In the recipe, Eclipta nourishes the liver and kidney, cools blood and stops bleeding; Ligustrum lucidum and mulberry nourish the liver and kidney; keel, oyster, mulberry Ye Pinggan Qianyang; Chinese yam, white peony root and rehmannia glutinosa nourish the liver and kidney; Poria invigorates the spleen and dampness; Chaihu soothes the liver and invigorates the spleen. The patient’s symptoms improved at the second consultation, and then added plantain to clear heat and diuresis, and Liuyi San to clear heat and disperse dampness.