A 40-year-old woman with a one-month history of morning dizziness, tinnitus, headaches, and night sweats was managed using a Qi-tonifying and Phlegm-dispelling herbal strategy.

Case ID: CHC-0038

Case Summary

This case describes a 40-year-old woman who presented with a one-month history of morning vertigo, tinnitus, headaches, and night sweats. The original report documented a conventional diagnosis of vertigo and a TCM assessment of Vertigo driven by Qi deficiency complicated by Phlegm. The patient was managed through a dynamic herbal approach designed to tonify the Spleen to rebuild foundational Qi while actively drying dampness and resolving the phlegm blocking her clear sensory orifices.

Patient Presentation

• Patient: 40-year-old female (Surname: Xie).
• Main Complaint: Dizziness upon waking accompanied by tinnitus for over one month.
• History: The patient sought consultation on January 18, 2018. She reported experiencing vertigo and tinnitus upon waking, along with headaches and night sweats. She had previously sought treatment at another hospital, but the results were unsatisfactory.

Examination and Diagnosis

• Conventional Diagnosis: Vertigo.
• TCM Tongue and Pulse: The tongue was pale and puffy with a white, greasy coating. The pulse was sunken and fine (脉沉细).

TCM Assessment

The original practitioner interpreted the presentation as Vertigo driven by Qi Deficiency complicated by Phlegm (眩晕 – 气虚夹痰证).

According to the holistic principles of yin and yang Chinese Medicine the Spleen and Stomach act as the source of Qi and blood production, as well as the center of fluid metabolism. The original report noted that the patient had an underlying weak constitution and poor Spleen function. Because her foundational Qi was deficient, clear Yang energy could not ascend to nourish her sensory orifices, directly resulting in her vertigo, tinnitus, and headaches.

Furthermore, the lack of Qi meant her defensive exterior (Wei Yang) was insecure, causing the night sweats. Crucially, the weakened Spleen failed to properly transform fluids, leading to the accumulation of internal dampness that condensed into Phlegm. This turbid Phlegm obstructed the middle jiao, further preventing clear Yang from rising and turbid Yin from descending. The pale, puffy tongue with a white, greasy coating and the sunken, fine pulse provided objective confirmation of this Spleen deficiency and Phlegm-dampness accumulation.

Treatment Approach

The primary treatment principle was to tonify Qi, strengthen the Spleen, dispel phlegm, and stop vertigo (益气健脾，祛痰止眩). The strategy aimed to rebuild the body’s internal metabolic engine while actively clearing the heavy, turbid blockage from the sensory pathways.

Herbal Formulas and Modifications

• Initial Formula (January 18, 2018): A 15-herb decoction balancing strong Qi tonification with aggressive phlegm resolution.
  • Tonifying Qi and Spleen: Shu Dang Shen (30g), Zheng Bai Zhu (10g), Huang Qi (40g), and Fu Ling (15g) form the core to strongly boost foundational Qi and rebuild the Spleen’s digestive function. Huang Qi (used in a heavy dose) and Fu Xiao Mai (30g) specifically boost Qi to secure the exterior and halt the night sweats.
  • Dispelling Phlegm and Drying Dampness: Jiang Shui Ban Xia (10g), Dan Nan Xing (10g), Zhi Shi (10g), and Gan Jiang (10g) strongly dry the heavy dampness and warm-transform the turbid phlegm. Shi Chang Pu (10g) awakens the Spleen and transforms dampness.
  • Calming Liver and Stopping Vertigo: Tian Ma (15g), Chao Jue Ming Zi (30g), and Duan Long Gu (30g) anchor the Liver, extinguish wind, and physically settle the dizziness.
  • Draining Dampness: Ze Xie (15g) provides a downward exit for the dampness. Gan Cao Pian (10g) harmonizes the decoction.
• Modification (Second Visit – January 24, 2018): The patient’s vertigo and tinnitus improved significantly, and the night sweats stopped, but the tongue coating remained thick and white. The practitioner shifted the focus to strengthening the Spleen, dispelling dampness, and invigorating blood to unblock the orifices (健脾祛湿，活血通窍). The heavy astringents and phlegm-scouring herbs (Dan Nan Xing, Huang Qi, Fu Xiao Mai, Duan Long Gu) were removed. Tao Ren (10g) and Chuan Xiong (10g) were added to move blood and unblock the vessels in the head, while Chai Hu (15g) and Yin Chen (15g) were added to regulate Qi and clear residual dampness.

Follow-Up

• January 24, 2018 (Second Visit): After taking the initial five doses (served warm morning and evening), the source reported a marked improvement in the patient’s condition. Her vertigo and tinnitus were significantly reduced, her headache had slightly improved, and she experienced no further night sweats. The formula was adjusted to consolidate the results by clearing the remaining dampness and promoting micro-circulation in the head.

Why This Case Is Interesting (Clinical Reasoning)

The notable feature of this case is the sophisticated management of a complex presentation combining both deficiency (Qi weakness) and excess (Phlegm-turbidity). When treating vertigo, it is common to simply use heavy Liver-calming or wind-extinguishing herbs.

However, the original practitioner recognized that the root cause was a metabolic “engine failure” (Spleen Qi deficiency) that was producing a physical blockage (Phlegm). By heavily tonifying Qi (using 40g of Huang Qi and 30g of Dang Shen) while simultaneously utilizing strong phlegm-resolving herbs (Ban Xia, Dan Nan Xing), the treatment successfully restored the body’s internal ascending and descending dynamics. This allowed the clear energy to rise and the turbid fluids to fall, effectively clearing the sensory orifices without exhausting the patient.

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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: Qingyuan Maternal and Child Health Hospital (清远市妇幼保健院) / Guangdong Provincial Administration of Traditional Chinese Medicine
• Original title: [【以案说医】曾宪进：益气健脾，祛痰止眩法治疗气虚夹痰型眩晕案]
• Practitioner: Professor Zeng Xianjin (曾宪进)
• Publication date: September 25, 2024
• Original language: Chinese
• ChineseHerb.org version: English translation and editorial adaptation