Mrs. Z, 65 years old, has a fat body and white skin, and has edema under her eyelids. First visit on November 25, 2018.
Chief complaint: edema for half a month, accompanied by wheezing, aggravated after activities.
History of present illness: The patient developed edema with wheezing without obvious incentive half a month ago, accompanied by tingling in the precordial area, which lasted for about 2-5 minutes, and the symptoms worsened, wheezing, fatigue, edema of both lower extremities, depressions when pressed, the patient She complained that her legs were as heavy as lead, her mouth was thirsty, but she didn't want to drink water. She urinated less than before and had dry stools, once every 2 days.
Physical examination: chubby and dark skin, water spots on the face, pitting edema in both lower extremities, slack “Astragalus sleeves” in both upper extremities, slack abdominal muscles, pale tongue with thin white fur, and slippery pulse.
Past history: hypertension, coronary heart disease, 7 years after pacemaker surgery.
Prescription: Fangji Huangqi Decoction plus Wuling Powder.
Prescription: Fangji 10 grams, Astragalus 30 grams, Poria 20 grams, Licorice 10 grams, Guizhi 15 grams, Alisma 15 grams, Atractylodes 30 grams, Polyporus 20 grams. 7 doses of decoction.
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| Licorice(GanCao) |
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| Atractylodes(BaiZhu) |
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| FangJi |
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| Astragalus(HuangQi) |
The second visit on December 3, 2018: The edema of both lower limbs was significantly reduced, there was no depression, and the leg sinking was also significantly reduced, the stool was smooth, once every two days, and the amount of urination was low. 7 doses of the original prescription were given and continued.
The third visit on December 11: the edema is no longer obvious, the wheezing has improved by 90%, the angina pectoris has not recurred, the stool is once a day, and the amount of urine is significantly increased compared with the previous one, and the effect is not better.
Prescription: Fangji 10 grams, Astragalus 30 grams, Poria 20 grams, Licorice 10 grams, Guizhi 15 grams, Alisma 15 grams, Atractylodes 15 grams, Polyporus 20 grams. 7 doses of decoction.
Note: The patient in this case is overweight, dark in skin tone, soft in skin, astragalus sleeves, and soft in abdominal wall muscles. It is considered as a gripper for the constitution of astragalus, accompanied by heavy limbs, thirst and urination, and considering that there is water in the body that cannot be excluded normally, so Fangji Huangqi Decoction and Wulingsan are used for conditioning.
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