General condition:XX Zhang, male, 46 years old, Nanyang City People, employees, no history of drug allergy was found. First visit on October 19, 2018.
Complaint: Intermittent dizziness and headache for more than 4 months.
History of present illness: Dizziness, headache, dry scalp, and blurred vision after exertion before April. Urgency, chest tightness, and occasional pain in the anterior area of the heart. The local hospital diagnosed coronary heart disease. The diagnosis and treatment effect was not good.
Traditional Chinese Medicine Diagnosis:Headache Disease
Syndrome: Hepatobiliary Depression and Heat Syndrome
Treatment: span>Cleanse liver and gallbladder
Preliminary prescriptions< span>:
Processing:10.19 Day Fangjia Yanhusuo 12g , Fried white peony root 15g, myrobalan 20g. 15 granules of traditional Chinese medicine, one dose per day, taken with water.
Notes:Patients with “dizziness, headache” “When the chief complaint comes to the doctor, TCM belongs to the category of “headache” and “dizziness”. The syndrome differentiation of headache “must be divided into internal and external deficiency”. Traditional Chinese medicine believes that the head is the “meeting of all yang” and “the house of clear yang”. Among the internal and external factors, wind and fire are the most likely to cause headaches. The so-called top of the mountain is only the wind, and the fire is the inflammation. The patient’s headache is caused by liver stagnation and heat generation, liver yang hyperactivity, and wind and yang disturbance, resulting in the failure of clear orifices to rise, and the failure of turbid yin to descend. . In the prescription, Bupleurum and Scutellariae reconcile and clear away heat to eliminate the evil of Shaoyang; lightly use rhubarb and citrus aurantium to reduce the heat knot of Yangming, promote qi and eliminate suffocation; citrus citrus shell regulates qi and blood to eliminate full pain in the heart; Pinellia and Stomach-lowering, with a large amount of ginger, to treat nausea and vomiting; jujube and ginger are compatible, can regulate body fluids with Yingwei, and harmonize the spleen and stomach. , Add gardenia and light tempeh to clear the mind and remove troubles, chrysanthemum and corn essence grass clear the liver and eyesight, and keel oyster calms the nerves. In the second consultation, the patient’s symptoms were relieved, and there were occasional chest pain attacks, so Corydalis was given to promote blood circulation and relieve pain, white peony root to soften the liver and relieve pain, and myrobalan astringent intestines to stop diarrhea.