Gender: Female
Name: Zhou Lanzhen
Age: 32 years old
March 29, 2005
Major complaint: Constant and severe
distending pains on the two sides of the head and extending to
the both sides of the face for 3 years. Dizziness. Thirst. Night
sweating. Fatigue and lack of strength. The stool is normal.
Frequent urination with burning sense.
Examination: thready pulse, the tongue
coating is thin and whitish. There are burning pains and
distension in the stomach.
Current diagnosis: 1.Trigeminal Pains 2.
Gastritis
Formula:
mulberry leaf 10g,
chrysanthemum
flower 10g,
poria
15g,
tribulus
15g,
ligusticum
root 10g,
moutan
bark 10g,
lycium
berry 10g cooked rehmannia root
20g,
gastrodia
10g,
salvia
root 15g,
four dosages
Dr. Ming
April 8, 2005.
She has been suffering from the trigeminal
pain for 3 years.
Strong needling pains and burning pains in
the face and the two temples; the pains are so constant that the
pains exist not only in the daytime but also at night. Poor
appetite and spirit.
No heart, lung and blood pressure problems.
The stool and urine are fine. The sleeping is not good.
Formula:
tangkuei
root 10g,
ligusticum
root 10g,
bupleurum
root 10g,
chrysanthemum
flower 10g,
pearch
kernel 10g,
codonopsis
root 15g,
ovate
atractylodes rhizome 10g
poria 10g,
Chinese
yam 10g,
scutellaria
root 10g,
moutan
bark 10g| schizonepeta 8g,
ledebouriella 8g,
mulberry
seed 15g
three dosages
Dr. Ming
April 28, 2005
Distending pains on the two sides of the
temples and radiating to the face.
Overwork and warmth could worsen the pains
while coldness could reduce the pains. No thirst and bitter
taste in the mouth. She has sour taste in the mouth after waking
up. Appetite and sleep are as usual. The stool and urine are OK.
Fatigue. Pains all over the whole body. Irritability.
The tongue body is slightly reddish. Tongue
coating is thin and whitish. Slippery, string-like and deep
pulse. Sore and painful waist which prefers pressure and warmth.
Formula:
dragon bone 30g, oyster shell 30g, gentian
root 5g, white peony root 20g, madder root 10g,
scutellaria root 10g,
prunella spike 10g, chrysanthemum
flower 10g, ligusticum root
20g, angelica dahurian 10g,
gardenia fruit 10g, curcuma tuber 10g, fresh
rehmannia root 20g,
lycium berry 20g
five
doasges
Dr. Ming
May 3, 2005
Still constant distending and needling pains
on the two temples. No pains from the forehead to the nose.
There are pains from the temples to the chin.
The patient is 1.5 meters high, 60 kilograms
in weight and 32 years old.
Everyday she only can do some light physical
labor.
In the past, the pains happened on the head
top also, but now disappeared. All these pains could be slightly
relieved by slight massage and by covering with the cold towel.
She occasionally takes some pain relief pill. Then she has the
lasting pains for a half day. No matter the season and weather
change, the pains are always the same. Last year, it pains very
severely for about 60 days.
Hair loss. No tinnitus. Eyes are neither dry
nor distention. She has occasional thirst and sour taste in the
mouth. Do not drink too much and prefer cold water.
Palpitations. No anemia. She sleeps 8 hours every day. Poor
spirit. Poor appetite. The stool is normal. The urine is
yellowish and night urine twice a day. There is numbness of the
limbs, waist and chest. No convulsion and aching pains in these
parts of the body. Dizziness. Rare night sweating. Burning sense
in the urethra and the stomach. Irascibility and easiness to be
angry.
Thready pulse. The tongue coating is
yellowish and thin.
Formula:
bupleurum
root 15g, gypsum 30g, scutellaria
root 15g, gardenia fruit 15g, pearch
kernel 12g, carthamus flower 12g, ligusticum
root 12g, silkworm 12g, earth worm 15g, notopterygium
12g, millettia root and stem 10g,
centipede 2 pieces red peony root 10g, toosendon
10g
Dr. Ming
May 17, 2005.
The pains have been reduced 50%. Pains in
left side of the head disappeared. Only the right side is
painful. It pains once each day, 1 hour each time. The appetite
is improved. The spirit and sleeping have good improvement.
Formula:
bupleurum
root 15g, gypsum 30g, scutellaria
root 15g, gardenia fruit 15g, pearch
kernel 12g, carthamus flower 12g,
ligusticum root 12g, silkworm 12g,
earth worm 15g, notopterygium 12g,
millettia root and stem 10g,
centipede 2 pieces, red peony root 10g, toosendon
10g
Dr. Ming
July 10, 2005.
