General:LiXX, female, 60 years old, unemployed, from Zhengzhou, Henan. No history of drug allergy was found. 2018 year07month10the first visit.
Complaint:Paroxysmal chest tightness, chest pain1more than a week.
History of present illness:1 A week ago, there was no obvious incentive for chest tightness and chest pain, which was paroxysmal and lasted for 10 minutes, and relieved after rest. degree of regurgitation, a small amount of mitral regurgitation, and decreased left ventricular diastolic function; Tone, red tongue, yellow and greasy coating, deep and thin pulse. Denial of other medical history.
Traditional Chinese Medicine Diagnosis: chest pain disease
Syndromes:Phlegm heat and blood stasis syndrome
< span>Treatment:Resolving phlegm, clearing heat, promoting blood circulation and dredging pulses
Initial prescription:
Processing:8< /span>monthly10Japanese traditional Chinese medicine15paid, one dose per day, taken with water.
201809month14 3diagnosis:Occasionally, after taking the medicine, there is acupuncture-like discomfort in the back of the sternum, which is in bursts Sex, sleep in general, two will adjust. The tongue is pale red, with tooth marks on the sides, thin yellow and greasy fur, and thin pulse.
Processing:8< span>Month28Japanese Fang Chaihu Change20g, plus Zhuru20g . Traditional Chinese Medicine Formula Granules15Pay, one dose per day, take with water.
Note:Patients over 500 years old, with The main complaint is “chest tightness and chest pain”. At the initial diagnosis, the tongue is red, yellow and greasy, and the pulse is deep and thin. Combined with the medical history and tongue and pulse, it can be seen that the patient’s spleen and stomach are deficient, and the spleen is the source of phlegm. Endogenous, phlegm stagnation over time turns heat, phlegm and heat are mutually obstructed, phlegm turbidity obstructs the heart pulse, heat evil burns yin blood inside, both of which can lead to sluggish blood vessels, obstruction of the heart pulse, and pain if it is blocked. It can be caused by chest arthralgia, and the syndrome can be phlegm-heat interlocking, heart-blood stasis, and the treatment should be to resolve phlegm and clear heat, activate blood and dredge the pulse, and use Huanglian Wendan Decoction combined with coronary heart2< span> sign square addition and subtraction. Huanglian Wendan Decoction comes from the volume of “Six Causes and Tiao Discrimination”. It has the effect of clearing heat, regulating qi and resolving phlegm. It is suitable for chest tightness, shortness of breath, and palpitations caused by internal disturbance of phlegm-heat. Resolves phlegm; Poria invigorates the spleen and dissipates dampness and dispels phlegm; Bitter almond reduces Qi and relieves asthma; Xiebaixin is stagnant, while Guizhi is pungent and warm, which can help heart-yang, and both phlegm and dampness are yin pathogens, and non-warming medicines cannot resolve them; Heart2 prescription and other medicines for promoting blood circulation and removing blood stasis such as peach kernel and rhodiola; licorice for reconciling various medicines. During the second consultation, the tongue quality became lighter, and the tongue coating did not appear to be yellow and greasy. Then, the application of Shengmai San and Shengxian Decoction was changed, and the meaning of nourishing qi and nourishing yin was taken to cure the root cause. In the third diagnosis, the tongue coating was slightly yellow and greasy, so Zhuru was added to clear away heat and resolve phlegm.