General:sheetsXX< span>, male, 61 years old, employee, from Zhengzhou, no history of drug allergy. 2018 yearDecember month11The first visit.
Complaint:poor sleep20years, worsening1months.
History of present illness: nearly In the past 20 years, there was no obvious incentive for poor sleep, and intermittently taking traditional Chinese medicine for conditioning. In the past 1 months, the symptoms have worsened, irritability, easy to wake up at night, and the symptoms are normal. Can sleep well, stools are normal, pale red tongue, thin white fur, and thin pulse. Past history: PCIpostoperative8years, hypertension20more than 18 years, diabetes mellitus2more than 2 years, after cholecystectomy18 years, currently taking aspirin, Atorvastatin, cilinglix, Danshen dripping pills and other drugs.
Physical examination: HR: 67times/scores, BP : 120mmHg/80mmHg.
Traditional Chinese Medicine Diagnosis:Insomnia< /p>
Syndromes:Heart-Yin Deficiency Syndrome
< span>Treatment:Nourishing Yin, clearing heat, promoting blood circulation and soothing the nerves
Preliminary prescriptions:
< p>December 19, 2018Revisit:After taking the medicine, the symptoms were relieved, and the symptoms were relieved.
Processing:12.11 Add He Shou Wu20g, Ophiopogon Radix15g, Traditional Chinese Medicine7< span>Pay, one dose a day, simmer in water.
Remarks:Insomnia syndrome differentiation , This case is a chronic illness with deficiency of qi and yin, lack of nourishment in mind and insomnia. “Golden Chamber Synopsis” “Consumption of exhaustion and exhaustion, inability to sleep, Suanzaoren Tang is the master”. In the recipe, fried sour jujube seed is used for nourishing the blood and nourishing the liver, nourishing the blood and relieving the soul and soothing the nerves; Poria and Fushen nourish the qi, calm the heart and soothe the nerves, Anemarrhena clears heat, benefits the yin and eliminates vexation, and is a ministerial medicine. Medicine; Professor Wang Zhentao believes that the use of soothing drugs is the key to the treatment of insomnia. In the prescription, lily nourishes yin and calms the nerves, acacia peel relieves depression and calms the nerves, and Shouwuteng Qianyang calms the nerves; To nourish blood and activate blood. Throughout the whole prescription, based on syndrome differentiation, combined use of tranquilizers, taking into account the blood circulation, it can achieve good results.