General condition:Patient Dong, female, 67 Aged, Han, from Zhengzhou City, history of drug allergy: none. First visit on March 15, 2016.
Complaint:Paroxysmal palpitations for half a year.
History of present illness:The patient has had paroxysmal palpitations for no apparent reason in the past six months. In the Armed Police Hospital, the 64-slice CT showed no obvious abnormality, and the electrocardiogram and 24-hour dynamic electrocardiogram were all normal, and no drug treatment was taken. Now the above symptoms have recurring episodes, in order to seek systemic treatment, I came to see a doctor. Satisfaction, normal sleep, two. Pale red tongue, thin white fur, thin pulse.
Prior History: Denied other medical history. Blood pressure: 120/60mmHg, heart rate 72 beats/min, regular heart rate.
Traditional Chinese Medicine Diagnosis:palpitations
Types of evidence:Mental restlessness
< span>Treatment:Reinforce Qi and resolve phlegm, soothe the mind
< span>Prescription for initial diagnosis: Re-visit on March 22, 2016: The patient’s palpitations were significantly relieved after taking the drug, and he did not complain of other discomfort. Thin white fur, thin pulse. BP: 136/82mmHg.
Treatment: The decoction continued on March 15th. 7 doses, decocted in water, one dose a day, divided into two warm doses.
Notes:The evidence of this prescription is Weakness of heart qi, caused by phlegm disturbing the mind. Weak heart qi, phlegm is generated from the inside, the qi is not warm, and the phlegm disturbs the spirit, so insomnia and dreams, upset and restless; heart qi is weak, and the heart is not nourished, then the palpitations are heavy; the tongue is pale red, the coating is thin and white, the pulse is deep and thin, All are evidence of a weak mind and a disturbed mind. To treat qi and resolve phlegm, soothe the nerves and fix the mind, add or subtract the Anshen Dingzhi Pills. Anshen Dingzhi Pill comes from Cheng Zhongling’s “Medical Heart Enlightenment” in the Qing Dynasty. In the prescription, Poria and Fushen invigorate the spleen and replenish qi, invigorate the spleen and invigorate the qi, relieve dampness, calm the heart and soothe the nerves; Shenglong tooth is important to calm the nerves; Yuanzhi, Jiechangpu, Zhuru resolve phlegm and soothe the nerves; Salvia miltiorrhiza and Sophora flavescens clear heat and nourish yin, activate blood and soothe the nerves; Acacia Skin, Sichuan bergamot, Yejiao rattan, fried jujube benevolence soothe the liver and relieve depression, nourish the heart and soothe the nerves.