Case 2

Case 2

Liu ×, female, 43 years old, a cadre, was first seen on November 21, 1980. One year earlier, the patient began experiencing generalized edema, accompanied by frequent urination, urgency, and dysuria. She was diagnosed with chronic pyelonephritis at Lanzhou Railway Center Hospital, where she stayed for over a month. The pus cells in her urine disappeared, but proteinuria remained around (+++). After discharge, her condition fluctuated between mild and severe; four months ago, she caught a cold and developed a fever, with sore throat, and the edema soon worsened. She was admitted to Gansu Provincial Hospital of Traditional Chinese Medicine with a diagnosis of chronic nephritis (acute exacerbation). During her hospital stay, she received combined Chinese and Western medical treatment, but the edema did not subside, and proteinuria remained (+++). The patient requested to be discharged on her own, and after discharge, the edema worsened, accompanied by sore throat and cough, poor appetite, and reduced urine output with painful urination. She came to our clinic seeking traditional Chinese medicine treatment.

Physical examination: body temperature was 37°C, pulse rate was 90 beats per minute, blood pressure was 17.6/13.1 kPa (132/98 mmHg), development was normal, nutrition was poor, the face appeared pale, generalized edema was moderate, the throat was red, and the tonsils were moderately enlarged. The heart was not palpated, but a grade II systolic blowing murmur was audible in the apex area; lungs were unremarkable, the abdomen was distended, with ascites present. The pulse was tense, smooth, and rapid, with slight weakness in the two fingers of the wrist. The tongue was red, with a slightly yellowish and greasy coating.

Laboratory tests: urinalysis showed proteinuria (+++), red blood cells (++), pus cells (+), and granular tubular casts 1–2 per low-power field. Blood routine: red blood cell count was 310,000/mm³, hemoglobin was 9 g/L, white blood cell count was 10,000/mm³, with neutrophils accounting for 79%, lymphocytes 21%. Blood cholesterol was 660 mg, total serum protein was 3.8 g/L, globulin was 2.2 g/L, albumin was 1.6 g/L. Ascites examination: the appearance was clear, with proteinuria (?). Western medical diagnosis: chronic nephritis, nephrotic type, combined with upper respiratory tract infection.

Traditional Chinese medicine diagnosis: the patient presented with pale complexion, generalized edema, lower back pain, dizziness, bitter taste in the mouth, sore throat, cough, chest discomfort, reduced urine output with red color, mild fever and chills, combined with the pulse and tongue color, indicating kidney deficiency with water overflow, and wind-heat entering the interior. The formula used was Jisheng Shenqi Tang combined with herbs that clear heat and detoxify:

Sheng Di 10 g, Shan Yu Rou 6 g, Shan Yao 10 g, Dan Pi 6 g, Fu Ling 10 g, Ze Xie 10 g, Rou Gui 10 g, Fu Pian 10 g, Niu Xi 10 g, Er Hua 15 g, Lian Qiao 15 g, Gong Ying 15 g, Baishang 15 g, Xia Ku Cao 15 g, Shi Wei 20 g, Bai Mao Gen 20 g. After taking 10 doses, the cough and asthma gradually subsided, the generalized edema slightly improved, and the ascites was absent. Urinalysis showed proteinuria (+++), red blood cells (+), granular tubular casts 1–2 per low-power field. The patient still had a pale complexion, generalized edema, lower back pain, tinnitus, fear of cold, and the pulse remained slow and weak, with a red tongue coated in white and greasy. The diagnosis was characterized by kidney yang deficiency, with water-dampness overflowing; the formula was adjusted to remove Er Hua, Lian Qiao, Gong Ying, Baishang, and Xia Ku Cao, and instead added Winter Melon Peel 20 g, Whole Bottle Gourd 20 g, Large Belly Skin 10 g, Seaweed 10 g, Kelp 10 g, Half Branch Lotus 15 g. After taking the medicine for over 100 doses, the edema subsided, the ascites disappeared, and the patient’s mental and physical strength improved significantly compared to before. Urinalysis showed proteinuria (+), red blood cells 0–2 per low-power field, no tubular casts were observed. Blood cholesterol was 300 mg, and the patient still had a pale complexion, a slight fear of cold, lower back pain, and edema in the face in the morning, but lower limb edema in the evening. The patient had poor appetite, occasional bloating and discomfort in the abdomen, a slow and weak pulse, and a swollen tongue. The diagnosis was characterized by spleen and kidney yang deficiency; the formula used was Jisheng Shenqi Tang combined with Baoyuan Tang with additions:

Sheng Di 12 g, Shan Yu Rou 6 g, Shan Yao 6 g, Dan Pi 6 g, Fu Ling 12 g, Ze Xie 10 g, Rou Gui 10 g, Fu Pian 10 g, Dang Shen 10 g, Huang Qi 20 g, Gan Cao 6 g, Po Gu Zhi 10 g, Yin Yang Huo 10 g, Ba Ji Tian 10 g, Han Lian Cao 10 g, and Yimu Cao 30 g. After taking the medicine for over 30 doses, urinalysis showed no abnormalities, and blood routine: hemoglobin was 15 g/L, red blood cell count was 480,000/mm³, white blood cell count was 9,800/mm³, with neutrophils accounting for 68%, lymphocytes 32%. Blood cholesterol was 220 mg%. The patient’s physical strength recovered, his energy levels rose, and he was able to return to work.