April 23, 2005

Zhang Xixiu, female, 32 years old, a resident in our local city Huaihua.

Dizziness lasted for 2 months and aggravated for 5 days. The patient complains that without any special reasons that she felt severe dizziness for two months and worse during recent five days. The accompanied symptoms are fatigue, aching pains of the back and legs, soft legs. The head has heavy and distending sense. Self-feeling hot sense in the soles and palms in the afternoon. Easy to sweat. The appetite is reduced. Dreaminess. There are dry throat and a bitter taste in the mouth, especially at night. The tongue coating is yellowish and greasy. No other symptoms and other disease history. Medications prescribed in western hospital could not help. Also, taking another herbal formula at another hospital made her dizziness and fatigue worsened as blow.

Its treatment strategy is tonifying the qi, fortifying the spleen, clearing heat and moistening the yin.

codonopsis root 12g  astragalus root  15g　ovate atractylodes rhizome 10g  poria  12g 　bupleurum 10g 　cimicifuge 5g   cooked rehmannia root 15g  Chinese yam  15g 　cornus fruit 10g 　moutan bark 10g  alisma tuber 10g  　amanerrhena 10g phellodendron bark 10g 　asparagus tuber 15g  ophiopogon tuber 15g 　dendrobium stem  15g 　tangkuei root  15g 　licorice root 10g

The diagnosis of our hospital:

Dizziness of kidney deficiency type

Our analysis is that the patient suffers from deficiency pattern dizziness due to kidney deficiency. So there is aching pains of the back. The former formula made the dizziness even more severe, because astragalus root and cimicifuge are warm in nature, yet the tongue coating of the patient is yellowish. Since the patient feels heavy sense and wrapping sense of the head, so there is dampness attacking from the outside.

In general, this headache is a special type, both due to internal deficiency and external excess dampness evil. So it is called the mixture of excess and deficiency in TCM, and also called the mixture of exogenous affection and internal damage.

Treatment strategy: tonifying the kidneys, clearing deficient heat, tonifying spleen and eliminating dampness.

codonopsis root  15g ovate atractylodes rhizome  15g  Chinese yam  10g  poria 10g amommum 10g  coix seed 15g　mulberry seed  15g  cuscuta seed  10g  lycium berry   10g  cornus fruit  20g  moutan bark  12g   phellodendron bark  10g  notopterygium  10g anemarrhena  10g   glehnia  12g   trichosanthes root 10g

Explanation of this formula: in this formula, codonopsis root, ovate atractylodes rhizome, Chinese yam, poria could help tonifying the spleen to enrich the qi to help fatigue. Amommum and coix seed could eliminating the spleen dampness since the tongue coating is greasy. Mulberry seed, cuscuta seed, lycium berry, cornus fruit could tonify the kidneys, since the kidney deficiency is the root of her headache. Moutan bark, phellodendron bark and anemarrhena could clear the deficient fire. Notopterygium could eliminating the damp covering the head since the head feels heavy and like being wrapped by something. Glehnia and  trichosanthes root  could enrich the fluids.

Three dosages, taking a dosage a day.

                                                                                                                                                     Dr. Zhu Ming

April 26. 2005

The patient felt no obvious relief of the symptoms. She still feels thirsty and liking cool drinks. Dizziness, head distention and heavy wrapping sense of the head. The spirit is poor. Soft legs and dreaminess. The appetite is not good. Palpitations. Yellowish urine. Twice night urination. There is hot sense in the soles and palms in the afternoon. The patient also reported the history of hepatitis B, yet the liver function check is normal. The right kidney area is suffering from aching pains. The tongue coating is yellowish and greasy. The tongue body is slightly enlarged. The wrist pulse indicates feeble kidney pulse. To continue with the former formula for three dosages.

                                                                                                                                                       Dr. Ming

April 29, 2005

Today the patient reported that during the last three days, the dizziness is being relieved obviously and steadily. Now the patient feels that 80% relief of dizziness, head distention and heaviness has been gained. The spirit is improved 60%. The soft legs are improved 50%. The appetite is good. Still slight dreaminess. Palpitations disappear. Twice night urination. Still slight bitter taste and thirst in the mouth. Slightly yellowish urine. The back pains disappear. Slight deficient sweating in the soles and palms in the afternoon. The pulse is soggy. The tongue coating is less yellowish and greasy. Adjust the formula slightly as below.

codonopsis root 15g　cuscuta seed  10g　bupleurum  12g　 ovate atractylodes rhizome  15g　lycium berry  10g　scutellaria root  10g 　Chinese yam  10g　cornus fruit  20g　poria 10g  moutan bark   10g  amommum 10g   phellodendron bark  10g  coix seed 10g  notopterygium  10g mulberry seed  15g anemarrhena  10g

To offer another three dosages.

                                                                                                                                                         Dr. Ming

May 3, 2005

The patient reports all the dizziness, head distention and heaviness disappear. The spirit recovered well. No soft legs and back pains. The appetite is good. Good sleep. There is no thirst and bitter taste in the mouth. Slightly yellowish urine. There is only slight hot sense in the soles and palms in the afternoon yesterday. The tongue coating is thin and slightly yellowish. The patient feels recovering quite well and no more treatment is advised to the patient.