General:horsesXX< span>, male,63 years old, farmer, from Zhoukou, Henan. No history of drug allergy was found. 2018 year06month29the first visit.
Complaint :Intermittent chest tightness and palpitations for 3 years, aggravating for 1 month.
History of present illness: patient with no obvious predisposing factors 3 years ago Palpitations, chest tightness, unable to lie supine at night, symptoms improved after a long sigh, the local hospital diagnosed as “heart failure“, intermittent oral furosemide, Xueshuantong, Shengui Capsules, Danshen dripping pills treatment, the above symptoms aggravated 1month ago, unable to lie down at night, palpitations after exercise, chest tightness, may occur during rest at night, poor appetite, poor sleep, unformed stool, urination . Denied other medical history. Pale tongue, thin white fur, thin pulse. Echocardiography: left ventricular end-diastolic diameter 79mm, LVEF28%, FS 13%, the whole heart is enlarged, the left heart is focused, the ventricular wall Diffuse hypokinesis and poor left ventricular function.
Traditional Chinese Medicine Diagnosis:Heart Failure
< span>Patterns:Yang-deficiency-water syndrome
Treatment:Wenyang Lishui
Preliminary prescription:
Second Clinic on July 13, 2018 span>Complained that the symptoms were significantly relieved after taking the medicine, and now there was occasional abdominal distention after drinking water, which was relieved after taking diuretics, and there was no discomfort. Dark red tongue, thin white fur, thin pulse.
Processing:6month< /span>29Sunfang Astragalus is changed to 45g, and cohosh is changed to 20g span>, plus Lobelia15g, Bupleurum15g. Traditional Chinese medicine 15paid, one dose per day, decoct in water.
2018year08month01dayThree consultations: occasionally chest tightness, nausea and vomiting, sleeplessness, and diarrhea. Dark red tongue, thin white fur, thin pulse.
Processing:JulyMonth13 In Japan, the soil Poria and Lobelia were removed, and the Astragalus was changed to 60g, and Agrimony 30g was added. Traditional Chinese medicine 15pay, one dose per day, decoct in water.
2018year08month17dayFour diagnostics:Occasional chest tightness and upper abdominal distention and discomfort after taking the medicine. Less appetite, poor appetite, sleep well, and two bowel movements. Red tongue, thin white fur, thin pulse.
Processing:8month1 Astragalus is changed to 75g, cohosh is changed to 24g, Bupleurum is changed to 24g, and Bellflower 15g is added >, Magnolia15g, Chinese medicine15pay, one dose per day, decoct in water.
2018year08month31day,2018 Year 09month14day,2018year09month28day, span>2018year10month19day, 2018year11month16< span>Day, 2018 yearDecember Month07 Regular follow-up visits.
2019year01month04dayRe-visit: The condition is stable after taking the medicine, no complaints of obvious discomfort. Dark red tongue, thin white greasy coating, moist pulse.
Processing: p>
Note:This patient has dilated cardiomyopathy, usually dilated cardiomyopathy. Most of them seek medical attention with symptoms of cardiac insufficiency or arrhythmia. Master Wang believes that the pathogenesis of this disease is based on deficiency and deficiency, and early qi deficiency is based, and blood stasis is the standard. In the late stage, the deficiency of the yang qi of the heart and the kidney, and the dereliction of duty due to the warmth, lead to the dysfunction of various zang-fu organs. Among them, qi deficiency and yang deficiency are the foundation, and blood stasis, phlegm turbidity, and water-dampness are the signs. Heart qi deficiency can not stimulate blood circulation and blood stasis, and kidney yang deficiency can not warm the body fluid and water dampness stops. The four diagnoses are combined with ginseng. In this case, the heart and kidney yang is deficient, and the water and dampness are stagnant. The proposed formula is Zhenwu Decoction. The original formula uses Fuzi as the monarch medicine. This product is pungent and sweet in nature and hot, and it is used to warm the kidney to help the yang, to transform the qi and move the water, and to warm the spleen and earth, and to warm the water and damp; Atractylodes atractylodes, spleen and dampness; Baishao is also an adjuvant, one of which is beneficial to urination to move water qi, “Benjing” says that it can “benefit urination”, and “Famous Doctors” also says that “Remove water and gas, benefit the bladder”; the two can prevent aconite from drying out heat and injuring the yin, so as to facilitate long-term consumption for relieving treatment; dry ginger warms the lungs and transforms the drink; adding Tinglizi purifies the lungs and relieves asthma; tea roots strengthen the heart and diuresis, activate blood, and clear heat Detoxification; Huixincao calms the mind and calms the mind; Zelan, Alisma, Rhizoma Imperatae, Tuckahoe promote blood circulation and diuresis; Jujube nourishes Qi and invigorates the spleen; Astragalus tonifies Qi, Cimicifuga lifts; Myrobalan is astringent for the intestines and stops diarrhea; Licorice harmonizes various medicines .
