General condition: Patient Wang, female, 34 years old, history of allergies: not found. First visit2018-11-16.
Chief complaint: intermittent palpitations, chest tightness for 7 months.
History of present illness: the patient developed paroxysmal palpitations and chest tightness after exertion 7 months ago, which lasted for a few minutes to half an hour, oral betalux, Qishen Yiqi Dripping Pill after treatment, the symptoms were reduced, the sleep was general, the hands were swollen in the morning, and the two stools were normal. BP: 124mmHg/80mmHg The tongue is dark red, the lichen is thin and white, and the pulse is thin.
Traditional Chinese medicine diagnosis: palpitations
Syndrome type: Heart Yang deficiency syndrome
Treatment: Wen Tong Xinyang
Initial Prescription:
2018-12-14Follow-up visit: The patient's palpitations were reduced after taking the medicine, no chest tightness, no swelling of the hands, sleep well, and normal stools. The tongue is dark red, white and greasy, and the pulse is thin.
Traditional Chinese medicine diagnosis: palpitations
Syndrome type: Qi and Yin deficiency syndrome
Treatment: Nourish qi and nourish yin
Second Prescription:
According to the language: heart qi deficiency is common in the early stage of palpitations, which can be manifested as lack of heart qi, lack of heart and blood, deficiency of heart and spleen, heart deficiency and timidity, etc., and long-term illness can lead to heart yang deficiency and heart yang deficiency. The heart and yang are weak, and there is no way to warm the yang mind, causing the heart to be uneasy and palpitating. Combined with the medical history, this case can be attributed to the symptoms of heart yang deficiency and restless heart, and the treatment is to warm and replenish the mind and calm the nerves, and then add or subtract the oyster soup with cinnamon licorice keel. Fang Zhong Guizhi Wen Zhen Xinyang; Licorice nourishes qi and nourishes the heart; Raw keel, raw oysters, and heart-warming grass are important to calm the nerves and calm the heart; Poria cocos and cocos are calming and calming; The second diagnosis complained of the reduction of palpitations, and the fourth diagnosis was combined with ginseng, which was changed to the syndrome of qi and yin deficiency, and the prescription was changed to four ginseng drinking and calming the nerves, and the treatment was to nourish qi and nourish yin, calm the nerves and palpitations.