The medical record is introduced as follows:
The patient is a 34-year-old female with acute lymphoblastic leukemia. After the bone marrow transplant, her kidney was damaged. In the last two months, she had a low-grade fever at night (many nucleic acid tests were negative), which western medicine could not effectively deal with. The patient starts at 5 pm every day, first he is afraid of the cold, then he starts to have a fever. He wakes up at about10-1in the middle of the night, full of sweat. I eat a small amount. Although I don't feel full, I don't want to swallow the food when I reach my mouth. I will vomit after lunch break. Even if you take a nap, you will vomit easily after waking up. Sleep quality is not good, I feel particularly irritable, and it is easy to wake up with dreams. Hydronephrosis, swelling and pain in the right kidney area, jumping sensation, frequent urination, burning sensation after urination, milky urine with sticky phlegm, and occasional blood color. Get up 2-3 times at night and defecate.
The patient's tongue is pale and greasy with white fur, with rotten roots, sunken tongue and blood stasis of sublingual collaterals. The left pulse is slippery, slightly astringent, closing adzuki beans, floating and hitting fingers, and slightly knotted; The right pulse slippery decimal is slightly astringent, heavy and slow.
In so many cases, how should I take the medicine? Can the prescription solve the problem? How many prescriptions were used? Is it directly piled up or tailored according to the formula? How to cut? Let's see what Master says.
Prescription:
20g of Alisma orientale, 0/5g of Poria cocos/kloc-,0/5g of Polyporus/kloc-,0/5g of Atractylodes macrocephala/kloc-,0/5g of talc/kloc-,0/0g of colla Corii Asini/kloc-(melt mixing), 6g of medulla tetrapanacis and Rhizoma Dioscoreae Septemlobae. Magnolia officinalis 10g, Pinellia ternata 10g, Scutellaria baicalensis Georgi 10g, bamboo shavings 15g, Poria cocos 15g, Fructus Aurantii Immaturus 10g, Pericarpium Citri Tangerinae 15g, and Eupatorium odoratum.
The second diagnosis: after taking Topp, the patients' symptoms improved, and the problems of low fever, insomnia and poor appetite that had plagued the patients for months were obviously improved. It's just urine. Besides, the stool is dry. Adding Fructus Gardeniae, Radix Bupleuri, Caulis Akebiae and Radix Rehmanniae.
The prescription is as follows:
20g of Alisma orientale, 0/5g of Poria cocos/kloc-,0/5g of Polyporus/kloc-,0/5g of Atractylodes macrocephala/kloc-,0/5g of talc/kloc-,0/0g of colla Corii Asini/kloc-(melt mixing), 6g of medulla tetrapanacis and Rhizoma Dioscoreae Septemlobae. Magnolia officinalis 10g, Pinellia ternata 10g, Scutellaria baicalensis Georgi 10g, bamboo shavings 15g, Poria cocos 15g, Fructus Aurantii Immaturus 10g, Pericarpium Citri Tangerinae 15g, and Eupatorium odoratum.
Judging from the course and symptoms of the patient, the patient's condition is complicated, including qi deficiency after transplantation, weakness of spleen and stomach in middle energizer, hunger and aversion to food, vomiting after sleep, insomnia and dreaminess, gallbladder stagnation and phlegm disturbance, frequent urination syndrome, namely blood strangulation and strangulation, and the most important thing is deficiency of true yin in triple energizer and low fever in the afternoon.
For complex diseases, it is definitely impossible to solve all the problems with a single prescription, and the prescription must be tailored according to the specific situation of patients. For this disease, Master used soup, Sanren decoction, Scutellaria baicalensis talc decoction, Wendan decoction, and Chengtiao decoction. During the follow-up visit, she also used Xiaoji Soup. All the prescriptions were tailor-made, some used the whole prescription, and some only used a few of them.
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Let's first look at the parties involved:
Zhu Ling decoction is from Treatise on Febrile Diseases, and it is indicated for damp-heat betting syndrome. Dysuria, fever, thirst, or insomnia, or cough, nausea, diarrhea, red tongue, white or yellow coating, and rapid pulse. It also treats bloody stranguria, painful urination, difficulty in salivation and abdominal pain.
Composition: Polyporus umbellatus (peeled), Poria, Alisma orientalis, Colla Corii Asini, Talcum (pulverized), etc. In the prescription, Polyporus umbellatus is the monarch, and it belongs to the kidney and bladder meridian, aiming at light infiltration and diuresis. I use the sweetness of Alisma orientalis and Poria cocos to benefit Polyporus. Alisma orientalis is cold and can release heat, and Poria cocos can strengthen the spleen and help transport dampness. Adding the sweetness and coldness of talc can promote diuresis and clear heat. Ejiao nourishes yin and moistens dryness, which is not only beneficial to injured yin, but also can prevent various drugs from infiltrating into it and seriously injuring yin and blood. The combination of five drugs, mainly promoting diuresis, supplemented by clearing heat and nourishing yin, embodies the compatibility characteristics of promoting diuresis without hurting yin and nourishing yin without blocking dampness. The water is wet, the pathogenic heat is cleared, the vaginal fluid and body fluid are restored, and all the symptoms are eliminated by themselves. This prescription can be used for heat stranguria, blood stranguria and hematuria, which belongs to the combination of yin deficiency and water heat. For treating stranguria, gardenia and plantain seeds can be added to clear heat and treat stranguria; For treating stranguria, cogongrass rhizome, Cirsium japonicum and Cirsium japonicum can be added to cool blood and stop bleeding.
Treatise on Febrile Diseases Sanren Decoction consists of almond, Pinellia ternata, talc, raw coix seed, Akebia stem, cardamom, bamboo leaves and magnolia officinalis. Indications: Dampness-temperature attack in summer, with dampness being heavier than heat syndrome. Headache, aversion to cold, heavy body pain, weakness of limbs, pale face, chest tightness, no hunger, body heat in the afternoon, white fur, no thirst, and thin and slippery pulse. This recipe is commonly used to treat damp-heat at the beginning, with pathogenic factors in qi and dampness being heavier than heat. Almonds in the recipe rise to the scorching qi, while qi is moist; Nutmeg is fragrant and moist, with wide qi and slippery temper. Coix lachryma-jobi is sweet and light in taste, cold in nature, permeable to dampness and diuresis, invigorating the spleen, and keeping damp heat away from lower energizer. The combination of three benevolence, eliminating three jiao is the monarch medicine. Talc, medulla tetrapanacis and bamboo leaves are sweet, cold and light, which strengthens the efficacy of monarch drugs in promoting diuresis and clearing heat. Pinellia ternata and Magnolia Officinalis are used as adjuvant drugs to eliminate dampness and dissipate stagnation. Looking at the whole prescription, it embodies the compatibility characteristics of Xuanhua Middle Jiao, Penetrating Lower Jiao and Dispelling Triple Jiao. All the symptoms can be eliminated by gasification and dampness, clearing heat in summer and leveling triple Jiao.
Qin Huang talc soup, also from Treatise on Febrile Diseases, consists of 9 grams of Scutellaria baicalensis Georgi, 9 grams of talc, 9 grams of Poria cocos, 6 grams of areca peel, 3 grams of cardamom and 3 grams of medulla tetrapanacis. Indications: Damp-heat pathogen in middle energizer, fever and body pain, sweating and pyrolysis, followed by fever, thirst without excessive drinking, or thirst without contention, yellow and smooth tongue coating and slow pulse. The recipe of Scutellaria baicalensis Georgi is bitter and cold, clearing away heat and drying dampness, talc, Poria cocos, Tetrapanacis tetrapanacis and Polyporus clearing away damp heat, and cardamom seed and areca nut peel removing dampness and benefiting water, and at the same time, it can smooth qi, so that gasification will be humidified. All kinds of drugs are combined to eliminate dampness and clear heat, and the symptoms can be solved by themselves.
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Wendan decoction comes from the theory of three causes and one disease syndrome. Ingredients: Pinellia ternata, bamboo shavings, Fructus Aurantii Immaturus, Pericarpium Citri Tangerinae, Glycyrrhrizae Radix and Poria.
Indications: Syndrome of stagnation of gallbladder and phlegm. Timid and easily frightened, dizzy and palpitation, upset and sleepless, dreaming at night; Or vomiting, burping, dizziness, epilepsy. The fur is white and greasy, and the pulse is slippery. The syndromes of this prescription are mostly caused by deficiency of gallbladder qi, emotional failure, gallbladder failure, qi stagnation and phlegm obstruction, phlegm turbidity and disharmony between gallbladder and stomach. If the gallbladder is disturbed by evil spirits and loses its tranquility, it will be timid and easily frightened, upset and sleepless, with strange dreams and panic at night; Disharmony between gallbladder and stomach, stomach disharmony, vomiting, expectoration, hiccup and palpitation; Clear phlegm can cause dizziness and even epilepsy.
In the prescription, Pinellia ternata is pungent, warm, dampness-drying, phlegm-resolving, stomach-harmonizing and vomiting-relieving, which is the monarch drug. I use bamboo shavings, which are sweet and slightly cold, clearing away heat and resolving phlegm, removing annoyance and stopping vomiting. Pinellia ternata combined with bamboo shavings has the functions of cooling, resolving phlegm and regulating stomach, and relieving vomiting and annoyance. Chenpi is hard and warm, regulating qi and relieving depression, eliminating dampness and resolving phlegm; Fructus Aurantii Immaturus tastes bitter and slightly cold, reducing qi and promoting stagnation, resolving phlegm and reducing swelling. The combination of dried tangerine peel and immature bitter orange is also warm and cool, and the function of regulating qi and resolving phlegm is enhanced. With poria cocos, strengthen the spleen and ooze dampness to produce phlegm; Add ginger and jujube to regulate the spleen and stomach. Ginger is also toxic to Pinellia ternata. With licorice as the guide, herbs are blended. Pinellia ternata, dried tangerine peel and ginger are relatively warm together, while bamboo shavings and immature bitter orange are relatively cold, so the whole prescription is not cold and dry, regulating qi and resolving phlegm and regulating stomach, lowering stomach qi and benefiting gallbladder, resolving phlegm and benefiting gallbladder. If so, it will restore its tranquility and heal itself.
There are two ways to distinguish between drinking and drinking. One is from medical understanding. Because its author is Cheng, it is called Cheng's Drinking. Comprises Rhizoma Dioscoreae Septemlobae, Cortex Phellodendri, Rhizoma Acori Graminei, Poria, Atractylodis Rhizoma, plumula Nelumbinis, Saviae Miltiorrhizae Radix and Semen Plantaginis. Indications: red and white turbidity is damp-heat. Zhu Lin. Rhizoma Dioscoreae Septemlobae and Rhizoma Acori Graminei are used together with Cortex Phellodendri and Semen Plantaginis to eliminate dampness and turbidity, which are cold in nature and treat damp-heat and turbid lower jiao. Kidney and bladder meridian are exterior and interior, and kidney qi is weak and cannot be consolidated. Bladder opening and closing disorder, urine turbidity can be distinguished from dysfunction, leading to urine turbidity. This prescription takes Rhizoma Dioscoreae Septemlobae as the main medicine, which promotes diuresis, clears away heat and dissolves turbidity, so it is called Rhizoma Dioscoreae Septemlobae to distinguish drinking.
Jishengfang Xiaoji Yinzi is composed of Radix Rehmanniae, Herba Cirsii, Talcum, Akebia Akebia, Pollen Typhae, Nodus Nelumbinis, Bamboo Leaves, Radix Angelicae Sinensis, Fructus Gardeniae and Radix Glycyrrhizae. Indications: heat-induced blood stranguria and hematuria. Hematuria, frequent micturition, redness, fever, pain, red tongue, and rapid pulse. The syndrome of this prescription is caused by blood stasis and fever in the lower jiao, damage to bladder blood collaterals and loss of qi. Cirsium japonicum in the prescription is sweet and cool into the blood, and it is good at clearing heat and cooling blood to stop bleeding, and it can also promote diuresis and relieve stranguria. It is especially suitable for hematuria and stranguria, so it is the monarch drug. Raw land tastes bitter and cold, cooling blood to stop bleeding, nourishing yin and clearing heat; Pollen Typhae and Nodus Nelumbinis are monarch drugs to cool blood, stop bleeding and remove blood stasis, and * * * is a minister drug. The combination of monarch and minister can stop bleeding without leaving blood stasis. The internal heat of lower coke should be guided by the situation, so talc, bamboo leaves and Akebia stem are used to clear away heat and promote diuresis for stranguria; Gardenia clears the fire of triple energizer and conducts heat from below; Angelica sinensis nourishes blood, leads blood to dredge collaterals, and has the effect of preventing cold and blood stasis of various drugs, so it is used as an auxiliary. Glycyrrhiza uralensis Fisch is used to relieve pain and regulate drugs. All the drugs are combined, with * * * cooling blood and stopping bleeding as the main prescription, supplemented by diuresis and stranguria.
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The main pathogenesis of the patient is yin deficiency and fever, and damp and heat are intertwined, so it is obvious that there is low fever in the afternoon, sweating in the middle of the night, and there are stranguria and bloody stranguria. Therefore, the selection of Zhu Ling decoction can not only clear away heat and promote diuresis, but also treat heat stranguria and blood stranguria. One side is multi-purpose, and the main side is Herba Cirsii to enhance the effect of cooling blood and stopping bleeding, and Herba Plantaginis to promote diuresis and clear heat. Because the urine color is white and turbid, it can be combined with Rhizoma Dioscoreae Septemlobae and Rhizoma Acori Graminei to treat the damp-heat and turbid syndrome of lower jiao, and only Rhizoma Dioscoreae Septemlobae and Rhizoma Acori Graminei are used to distinguish turbidity, without the whole prescription. The patient's dampness permeates the triple energizer, and the dampness and heat are intertwined. Therefore, Sanren Decoction is used to remove the dampness of triple energizer, and Qin Huang Talcum Decoction is used to clear its heat. Both Qin Huang Talcum Decoction and Sanren Decoction use nutmeg, medulla tetrapanacis and Talcum to clear away heat, promote diuresis and treat dampness. However, Scutellaria baicalensis Georgi, Erling, and Pericarpium Arecae are still added to Scutellaria baicalensis Georgi and Talcum Decoction, which has a stronger heat-clearing effect than Sanren Decoction, and is suitable for those who are stuck together due to pathogenic factors and pay equal attention to damp heat. Sanren Decoction uses almond, coix seed, bamboo leaves, Pinellia ternate and Magnolia Officinalis. In the process of promoting qi circulation and promoting diuresis, the effect of eliminating dampness is better than that of Qin Huang talc decoction. The combination of the two not only clears away heat and dampness, but also strengthens the role of eliminating dampness and clearing heat. Because Sanren Decoction has long been a medicine for promoting qi circulation, the medicines for promoting qi circulation, such as areola skin and poria skin, were removed from Qin Huang Talc Decoction, and only the meaning of clearing heat was taken. However, patients are still upset and sleepless, with strange dreams at night and easy vomiting after sleep, so Wendan Decoction is used to treat gallbladder depression and phlegm disturbance. Wendan decoction Pinellia tuber can eliminate dampness and eliminate phlegm, regulate stomach and stop vomiting, and bamboo shavings can clear away heat and eliminate phlegm, remove annoyance and stop vomiting. Pinellia ternata and bamboo shavings are mixed together to eliminate phlegm and stomach, stop vomiting and relieve annoyance. At the same time, Eupatorium odoratum and Pogostemon Pogostemonis are added to awaken the spleen with fragrance, and eliminate dampness and turbidity. All the above parties, add and subtract, cut and combine skillfully, with few drugs but remarkable effect. At the second diagnosis, all symptoms improved except urination. Therefore, on the basis of the original prescription, Xiaoji's prescription was added to strengthen the effect of clearing away heat and treating stranguria.
The difficulty of doctors is that they can't accurately treat according to syndrome differentiation and can't treat according to syndromes.
It is even more difficult to have a little knowledge of syndromes. How to find the intersection of main syndromes and various syndromes in complicated diseases and syndromes makes me at a loss.
In addition, it is difficult to find the main syndrome and coincidence point, and how to prescribe drugs.
To sum up, we can get some enlightenment from the discussion of complex pathogenesis in Master Fang, and it is also very helpful for how to add, subtract and modify prescriptions.
If carefully scrutinized, it will be of great benefit to learning Chinese medicine.