A 42-year-old man with a one-year history of vertigo and hypertension was managed using a dual herbal strategy to clear damp-heat and subdue hyperactive Liver Yang.

Case ID: CHC-0019

Case Summary

This case describes a 42-year-old man who presented with a one-year history of dizziness, head distension, and elevated blood pressure. The original report documented a Western medical diagnosis of hypertension and a TCM assessment of Vertigo driven by Liver Yang hyperactivity complicated by Liver and Gallbladder damp-heat. The patient was managed using a combined herbal formula designed to clear the metabolic damp-heat while anchoring the rising Yang energy.

Patient Presentation

• Patient: 42-year-old male.
• Main Complaint: Dizziness and head distension for over one year, accompanied by elevated blood pressure.
• History: The patient experienced persistent dizziness and head pain that noticeably worsened during emotional fluctuations or physical fatigue. Associated symptoms included irritability, a bitter taste in the mouth, and poor sleep with frequent dreams. His blood pressure had been repeatedly measured as elevated (up to a maximum of 145/95 mmHg), but he had not yet initiated pharmacological treatment for it. His appetite, bowel movements, and urination were reported as normal.

Examination and Diagnosis

• Conventional Diagnosis: Hypertension.
• TCM Tongue and Pulse: The tongue was red with a white, greasy coating. The pulse was deep and stringy (沉弦).

TCM Assessment

The original practitioner interpreted the presentation as Vertigo driven by Liver and Gallbladder Damp-Heat and Liver Yang Hyperactivity (眩晕 – 肝胆湿热，肝阳上亢).

According to the principles of Yin and Yang Chinese Medicine, water (Kidney Yin) must continuously nourish wood (Liver Yin) to keep the Liver’s active Yang energy properly anchored. The original report noted that the patient’s habit of staying up late depleted his Kidney Yin. Without sufficient Yin to anchor it, the Liver Yang became hyperactive and rushed upward to the head, causing the dizziness and high blood pressure.

Furthermore, the patient’s history of regular alcohol consumption generated internal damp-heat, while chronic emotional stress caused Liver Qi to stagnate and transform into fire. This combination of rising Wind-Yang and trapped Damp-Heat harassed the clear sensory orifices and agitated the mind, resulting in the bitter taste, irritability, and disturbed sleep.

Treatment Approach

The primary treatment principle was to clear and resolve damp-heat, calm the Liver, and subdue Yang (清利湿热，平肝潜阳). The strategy required a multi-pronged approach to address both the neurological-like symptoms of rising Wind and the metabolic accumulation of damp-heat.

Herbal Formulas and Modifications

• Formula Prescribed (Initial Visit – April 14, 2023): The practitioner combined modified versions of two classic formulas: Chaiqin Wendan Tang (Bupleurum and Scutellaria Decoction to Warm the Gallbladder) and Tianma Gouteng Yin (Gastrodia and Uncaria Beverage).
  • Calming Liver and Subduing Yang: Tian Ma (Gastrodia), Gou Teng (Uncaria), and Luo Bu Ma Ye (Apocynum leaf) specifically anchor hyperactive Liver Yang and extinguish internal wind to address the dizziness and hypertension.
  • Anchoring the Spirit: Duan Mu Li (Calcined Oyster Shell) and Duan Long Gu (Calcined Dragon Bone) heavily settle the floating Yang and calm the agitated mind to improve sleep.
  • Clearing Damp-Heat and Regulating Qi: Bei Chai Hu (Bupleurum), Huang Qin (Scutellaria), Zhi Shi (Immature Bitter Orange), Bai Zhu (Atractylodes), and Fu Ling (Poria) clear localized heat, dry dampness, and restore the proper ascending and descending mechanics of the digestive system.
  • Nourishing Liver and Invigorating Blood: Bai Shao (White Peony) nourishes Liver Yin to soften the Liver. Dan Shen (Salvia) and Chi Shao (Red Peony) invigorate blood circulation, addressing the micro-circulatory stasis caused by prolonged illness (as later evidenced by sublingual vein engorgement).

Follow-Up

• October 20, 2023 (Second Visit): At the subsequent documented visit, the source reported a significant reduction in the patient’s dizziness and head distension following the initial course of medication. The bitter taste in his mouth improved, his sleep was better, and his emotional state was more stable. His blood pressure was measured at 136/84 mmHg. The practitioner maintained the exact same formula to consolidate the results and advised comprehensive lifestyle adjustments (low-salt/low-fat diet, regular exercise, moderated alcohol intake, and avoiding late nights).

Why This Case Is Interesting (Clinical Reasoning)

The notable feature of this case is the sophisticated management of modern lifestyle-induced hypertension. Rather than simply using herbs with known hypotensive properties to forcefully lower blood pressure, the original practitioner addressed the complex systemic environment creating the symptom.

The treatment acknowledges that modern hypertension often features a dual pathology: the “deficiency” of staying up late (Yin depletion leading to Yang hyperactivity) and the “excess” of rich diets and alcohol (Damp-Heat). By combining Tianma Gouteng Yin (which treats the rising Wind/Yang) with Chaiqin Wendan Tang (which cleans up the digestive Damp-Heat), the practitioner successfully stabilized the patient’s blood pressure and relieved the vertigo by restoring the body’s internal equilibrium.

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What This Case Can — and Cannot — Tell Us

This is an individual case report, not a controlled clinical trial. It documents the reasoning, treatment, and outcome reported for one patient and should not be interpreted as evidence that the same approach will produce the same result in another person.

Source

• Original source: Beijing University of Chinese Medicine Shenzhen Hospital (Longgang) / Guangdong Provincial Administration of Traditional Chinese Medicine
• Original title: [【以案说医】王进东：眩晕因由湿热起，平肝清利症状消]
• Practitioner: Professor Wang Jindong (王进东)
• Publication date: October 23, 2024
• Original language: Chinese
• Source link: [View original page]
• ChineseHerb.org version: English translation and editorial adaptation