Western Diagnosis: 1. Indigestion. 2. Hypertension
History: Male. 63 years old.
Patient had had indigestion on and off for 8 months, continuous for last 2 months.
Drugs: had been taking and Angiotensin II Inhibitor for HBP for some time. Dosage increased 2 months ago. Antacid tablets for indigestion last 2 months
Symptoms: Abdomen: bloating at epigastrium, belching, worse when lying down at any time, worse during meditation, better for doing yoga.
Throat: patient was clear he had a sensation like a small fruit stone in his throat.
Tiredness: After eating. Slight tiredness in late afternoon. Very lively in evenings.
Hot/Cold: Feels cool after eating, worse in cold weather
Sleep: good, except when wakened by indigestion
Diet: Wife makes him eat a lot of salads and raw food, though he would rather not
Palpation: Wiry, slippery
Observation: TB: maroon
TC: Greasy yellow at back and middle. Thin and wet elsewhere
OM Diagnosis: Phlegm dampness in middle jiao with Stagnation of Qi. On background of Liver Yang/Yin Xu
Treatment Principle: Boost Spleen, transform Phlegm and Dampness to Disperse Qi. Subdue Liver Yang and support Yin
Point Prescription: Feng Long, Zhong Wan, Nei Guan, Yang Ling, San Yin Jiao
Herb Prescription: This patient was relatively uncomplicated so I unusually opted to treat him with herbal pills instead of decoctions on this occasion:
Ban Xia Hou Po Tang, and Tian Ma Gou Teng Wan
Lifestyle Prescription: Avoid cold and raw food
Results: After one week he returned having decided unilaterally to reduce his Angiotensin II Inhibitor by half. He had been measuring his blood pressure every day: 125/78.
Throat: Sensation of small lump completely gone
Abdomen: Minimal bloating. Has not needed to use any antacid tablets all week.
Face: still red
Tiredness: no longer tired after eating. Still gets very lively in evenings
Sleep: not wakened by indigestion any more
Diet: Says it is very difficult for him to stop taking cold/raw food. I again advise him strongly to avoid cold or raw food. Domestic issue at work.
Synopsis: This patient in the long term view is Liver/Kidney Yin Xu with Liver Yang Rising.
The indigestion and plumstone throat was caused by the cold nature of the Angiotensin II Inhibitor drug and got worse when this dosage was increased.
Therefore my strategy was to rectify the Phlegm Dampness while simultaneously Subduing Liver Yang to give him scope to reduce and ultimately eliminate his drug.
This strategy was straightforward and worked well.
He needs to work more on avoiding cold and raw food and have this issue out with his wife, who now understands that the medicine is working well and has consulted me herself.
Once his drugs are completely removed his herbal treatment can switch from Tian Ma Gou Teng Wan to something like Ming Mu Di Huang Wan in order to Nourish his Yin, remover the afternoon tiredness and help him to be more reposed in the evenings, while maintaining his blood pressure at good levels.