Medical Record Number: 72487078, female, middle-age

Chief Complaint: Insomnia & Heat in Feet Sole

First visit: June 29, 2018

Medical History: The patient complaints of poor sleep, facial chloasma, gain body weight, hot temper, LMP on 2018/06/08, dysmenorrheal with lots of blood clots, dry stool, aversion to cold, stomach discomfort after cold food or fruit, has mouth ulcer for several times last year. Pulse is deep, slippery and soft.

Diagnosis: Insomnia, Chloasma.

TCM Differentiation: Deficiency fire flaming upward

Treatment Strategy: Subdue yang and tranquillize spirit, and clear heat in upper body and warm lower body

Prescription:

For 7 doses, one dose every day, and decocted in water twice a day, take it when the decoction is warm.

Second Visit: Most symptoms were relieved greatly; heat in the soles of feet was reduced, sleep and bowel movement become normal. Pulse is deep, slippery and soft. Prescription: modifies last formulae by subtractingsuan zao renandbai zi ren, addingzhu ling, ze xieandsheng bai zhu, 14 doses.

Third Visit: The heat in the soles of the feet is basically relieved, occasional has mouth sores. The pulse is thin and slippery. Prescription: modifies last formulae by subtractingshi cang puandsheng jiang, addinglu gen, bai zhiandchuan xiong, 14doses.

Fourth visit on July 30: The heat in the sole of the feet is relieved and facial brown chloasma become lighter. The tongue is pale with a thin white coat. Prescription: modifies last formulae by subtractinglong dan cao, niu xiandsang ye, addingtao rento consolidate the treatment, 14 doses.

Note: Patient is female, on middle age. InInner Cannon of Huangdi, itsaid “For people at the age of 40, half of the Yin Qi in their body has already been consumed; early aging begins to appear in their daily activities.” Plain Questions•Discourse on the True Heaven in High Antiquity:“At the age of thirty-five, Yangming Channel starts to decline, the face begins to dry out, the hair begins to fall off. At the age of forty-two, as the three Yang Channels are deficient, the countenance becomes wane and the hair begins to turn white.”Therefore, there is a deficiency of essential qi, the face begins to have brown maculae. Yin fails to embrace Yang,Yang root become loosen. Therefore Yang Qi rushes upward to the liver, liver qi floats astray outward, and deranges and disturbs heart, resulting in restless, poor sleep; if it rushes downward to the feet, resulting in heat in the soles of feet. Ying depletion and Yang bind results in dry stool.

Inner yang floating outward caused deficient of inner yang, resulting in weakness of the warming power of zang-fu organs and the appearance of the manifestations of visceral cold, such as aversion to cold, stomachache when eat cold food, dysmenorrheal and blood clots, and weight gain due to yang deficiency and water diffusion.

Initial Visit: Gui Gan Long Mu Tang is to subdue yang and tranquilize spirit.He huan piresolves depression and calm the spirit; sheng jiang andding xiangwarms the center and dissipates cold;jiu cong rong, bo zi renandsuan zao renmoistens intestines to relieve constipation and calm spirit;niu xireturns fire to it origin;long danclears the liver and drains fire;sang yeclears exterior heat and outthrusts fire pathogen and good at dissipates the heat in the soles of the feet.

Second Visit: The patient had normal sleep and bowel movement. The heat in the soles of the feet was improved. The previous prescription was modified by subtractingsuanzaorenandbo zi rento calm the spirit, addingsheng bai zhuinvigorates spleen and relax the bowels,ze xieandzhu lingpromotes urination to drain dampness and abduct heat away from urine.

Third Visit: The heat in the soles of the feet had basically disappeared without recurrence. The patient had aphtha. Therefore, subtractedsheng jiangwhich mobile on the exterior and disperse outward and tend toward heat,shi chang puto free the orifices and mobile and piercing,long dan,andsang yeto clear heat; Addedlu genclear heat and engender liquid,baizhi, chuan xiong,andtao renmove qi, activate blood, and expel turbid to keep roads open. Qi, blood, fluid and humor had been gradually restored and facial brown macules faded.