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Abstract: A 48-year-old aunt indicated that she had poor sleep quality for about 5 years, usually waking easily from sleep, timid, often startled by loud noises, often anxious and depressed. After consulting the doctor, it was considered to be caused by the deficiency of heart and gallbladder qi. The heart is the master of the mind and the gallbladder is the official of the middle right, when the heart and gallbladder qi is deficient, the mind is not full of qi and the gallbladder qi is deficient, so the above symptoms will easily appear. The patient was later given herbal treatment and received good results after 2 months.
Basic information】Female, 48 years old
Type of disease】Heart and gallbladder Qi deficiency
Hospital】Daqing Traditional Chinese Medicine Hospital
Date of consultation】June 2022
Treatment plan】Warm Gallbladder Soup + Gui Zhi + Dragon Bone + Oyster + Chicken Nei Jin + Fried Wheat Germ + Raw Atractylodes + Chai Hu + Baicalin
Treatment Period】2 months of outpatient treatment
Effect】Improved sleep state, sufficient energy, easy to be frightened
I. Initial consultation
The patient, a 48-year-old female, reported that she had been suffering from neurasthenia and poor sleep for more than 5 years, and was easily frightened, especially in a quiet environment, when there were loud noises or sudden ringing of the phone. He had been taking Xie Yu An Xin granules, Jin Shen Xie Liver Capsules and Yang Xin Sheng Pulse Granules on his own, but there was no significant change in his sleep and startle-prone symptoms. At the time of consultation, the patient indicated that he was usually afraid of cold, cold hands and feet, lack of energy, poor memory, depressed mood, yellowish face, poor appetite, dry stools, light tongue with slightly greasy coating, and smooth pulse. Based on the patient’s tongue, pulse and symptoms, the patient is considered to be suffering from deficiency of heart and gallbladder Qi in TCM. Treatment is needed to nourish the heart and tranquilize the mind, dredge the gallbladder and promote the flow of Qi.
II. Treatment history
According to the TCM identification system, for the evidence of deficiency of heart and gallbladder qi, we applied the method of nourishing the heart, calming the mind, and draining the liver and gallbladder, based on warming gallbladder soup, adding cinnamon branch, dragon bone, oyster, chicken internal gold, fried wheat sprout, and raw atractylodes decoction to take the treatment, and returned to the clinic after 1 week. At the second meeting, the patient did not improve significantly, but his bowels were clear and his appetite slightly improved. Considering that the patient had a long course of illness, the original formula continued to treat him as it could not be effective in a short time. At the second visit, the patient’s appetite was better, the stool was basically normal, the feeling of coldness was slightly improved, the self-consciousness of sleepiness was obvious, the mouth was slightly bitter, and on the basis of the above, Chai Hu and Scutellaria were added to dredge the liver and gallbladder, and to reach Shao Yang for the purpose. The fourth follow-up patient many symptoms have improved, mild sweating, short sleep, but sleep does not wake up, the prescription remains unchanged, continue to consolidate this program until 2 months.
III. Treatment effect
The patient was treated for 2 months from the first consultation to the last consultation. After the TCM evidence-based treatment, the patient’s heart and gallbladder Qi deficiency symptoms were greatly improved. At the end of the consultation, the patient slept for 5-7 hours, had fewer dreams, basically did not wake up in the middle of sleep, his mood improved significantly, his fear of cold and chill improved, his diet and bowel movements were normal, and the problem of loud voice fright was also improved. The symptoms were solved after the TCM identification treatment, and the patient felt that the physical state and mental state were significantly different from those before the treatment.
IV. Notes
I am glad that after the herbal treatment, the patient’s symptoms were significantly improved. For this patient, the insomnia and anxiety state is longer and easy to be repeated in treatment, so it is necessary to communicate well with the patient and guide good psychological adjustment. When stimulated by external environmental changes or poor mood, the original discomfort symptoms may be repeated or aggravated, therefore, on the basis of taking Chinese medicine treatment, it is necessary to adjust one’s mentality. Appropriate exercise is very helpful to promote recovery, especially doing yoga or tai chi, etc., which can assist in strengthening liver qi regulation, bile qi promotion, and promote the stability of the mind. Diet also requires restraint, cold fruits, drinks and fatty, sweet and thick foods will affect the development of bile qi, so the diet should be light.
V. Personal Insights
The symptoms of heart and gallbladder Qi deficiency are often similar to neurosis, with patients having sleep problems and anxiety. And heart and gallbladder qi deficiency is easy to repeat, not easy to work, just rely on drugs is not effective, but also psychological adjustment, appropriate physical activities, socialization, etc., are helpful to the disease, after the correct understanding of the disease, in order to have a good therapeutic effect, so it is also recommended that the patient can have a good state of mind.