General:leafXX, female, 51 years old, unemployed, from Yuncheng, Shanxi. No history of drug allergy was found. 2018year07month11day.
Complaint:Discovered “Dilated Cardiomyopathy”2years.
History of Present Illness:Patient 13years ago due to symptoms of chest tightness after a cold, and was diagnosed with viral myocarditis in a local hospital. Due to dilated heart disease, the patient has no obvious discomfort, normal blood pressure is low, sleep well, normal stool, small amount of urination, pale red tongue, thin white coating, thin pulse. Previously healthy; denied other diseases. Physical examination: HR: 63times/ Score, Law Qi, BP:85mmHg/60mmHg. Auxiliary examination: Cardiac ultrasound: left ventricular diameter61mm, EF 30%< /span>, enlarged left atrium and left ventricle, diffusely weakened left ventricular wall motion, moderate mitral regurgitation, poor left ventricular function (systolic +< span > diastole).
Traditional Chinese Medicine Diagnosis:Heart Failure< /p>
Syndromes:Qi deficiency and blood stasis
Treatment:Replenishing Qi, Huoxue and Water
Prescription prescription:20
Processing:7< span>Month11Japanese Fangzhi Astragalus is changed to 45g, and cohosh is changed to 18g, Bupleurum to 20g, Platycodon to 18g, Tea Tree Change the root to 60g, add Amomum 12g, Tuckahoe30g span>. Traditional Chinese medicine 20paid, one dose per day, decoct in water.
August 31, 2018Three visits: Stressed and uncomfortable under the xiphoid process when emotionally tense, but no obvious discomfort, normal sleeplessness, and dyspnea. Pale red tongue, thin white fur, thin pulse.
Processing:8< span>Month3Japanese Fangzhi Astragalus changed to 75g, Codonopsis to 30g, Cimicifuga, Bupleurum, Campanulaceae to 24g, Five-clawed to 60g, traditional Chinese medicine20paid, one dose per day, decoct in water.
October 30, 2018< span>Four diagnostics: Complaints of palpitations, chest tightness, repeated colds, vomiting during colds, drowsiness and weakness of both lower extremities, anorexia, poor appetite , Poor sleep, difficulty falling asleep, and fecal adjustment. Pale red tongue, thin white fur, thin pulse. Echocardiography: left ventricular diameter 58mm, EF 35%, left atrium and left ventricle enlarged, left ventricular wall motion was diffusely weakened, moderate mitral regurgitation, Decreased left ventricular systolic function.
Processing:8.30< span>Japanese Astragalus changed to 100g, Cimicifuga changed to 30g, Bupleurum to span>30g, Campanulaceae to 30g, plus acacia peel24g. 20dose, decoct in water, one dose a day, divided into 2times.
Note:Dilated cardiomyopathy is a primary Cardiac disease characterized by left or right ventricle or bilateral ventricular enlargement with ventricular systolic hypofunction, with or without congestive heart failure. Under normal circumstances, the onset of dilated cardiomyopathy is insidious, and most of them are treated 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. Among them, qi deficiency and blood stasis are not only the internal cause of the onset of dilated cardiomyopathy, but also the result of the disease, which exists in every link in the development of the disease. Therefore, the treatment of nourishing qi and promoting blood circulation should be used throughout the treatment of this disease. The four diagnoses are combined with ginseng. This case belongs to Qi deficiency, blood stasis and water stasis. The treatment is to nourish Qi, activate blood and diuresis. Fangzhong Sijunzi Decoction Codonopsis, Poria, Atractylodes spleen, astragalus, five-clawed dragon enhance the power of qi; Cimicifuga, Bupleurum, Platycodon grandiflorum raise Yang depression; old tea tree root strengthens the heart and diuresis, promotes blood circulation, clears heat and detoxifies; Heart grass calms the mind and calms the mind; Agrimony, Leonurus, Rhizoma Imperatae, Zelan, Alisma, Psyllium Huoxue diuresis; Add Ophiopogon japonicus to nourish yin, to make western medicine diuretics harm Yin; Geshanxiao, Licorice and Zhong, Licorice There are reconciling medicines. After regular follow-up visits, Mr. Wang gradually increased the dosage of Astragalus, Cimicifuga, Bupleurum, etc., on the one hand, adjusted the dosage of ACEIand β-blockers,3months, the echocardiography showed that the heart contracted and the left ventricular function improved. Continue to use this prescription as the basis to consolidate the curative effect, thereby improving the patient’s condition.