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Abstract: The patient was a 73-year-old man who was admitted to the hospital with weakness of the extremities with syncope, associated with paroxysmal vague pain in the left lower abdomen, poor nausea, dry mouth and bitterness. He had a previous history of type 2 diabetes mellitus and was not taking oral hypoglycemic agents regularly as well as subcutaneous insulin injections. The patient’s condition was controlled and her symptoms gradually disappeared.
Basic information】Female, 73 years old
Disease Type】Heat
Hospital】Rizhao City Hospital of Traditional Chinese Medicine
Date of consultation】June 2022
Treatment plan】Western medicine (piperacillin sodium tazobactam sodium for injection) + Chinese medicine (calamus yujin tang plus reduction)
Treatment period】7 days in hospital
Treatment effect] The disease was controlled and the symptoms gradually disappeared.
I. Initial consultation
The patient was admitted to the hospital due to weakness of the limbs with syncope. At the time of admission, the patient had paroxysmal vague pain in the left lower abdomen, accompanied by poor nausea, dry mouth and bitterness of the mouth. Family member’s description: 5 hours ago, the patient had a sudden onset of syncope, loss of consciousness, and urinary incontinence. He had a history of type 2 diabetes mellitus for many years without regular oral hypoglycemic drugs or subcutaneous insulin injections.
The cranial MRI showed bilateral periventricular white matter demyelination and cerebral arteriosclerosis, but no significant stenosis or abnormal dilatation was observed, and no cerebral infarction or hemorrhage was detected. After completing the nucleic acid test for the new coronavirus, he was admitted to the hospital. After admission, he was examined: high blood sugar, high fever, and a body temperature of 39℃. The Chinese medicine examination showed flushing on both sides of the zygomatic area, and the tongue was slightly dry with little moss on the anterior side and slightly yellow with greasy moss on the middle and posterior side; the pulse was mainly thin, soft and counted on both sides of the guan-zhu section, and the left side of the inch section was obviously floating and slippery, while the right side of the inch section was floating and slippery with a slight depression. In addition, the patient had symptoms of high fever, irritability, thirst, and weakness of the limbs.
(Head Magnetic Resonance Imaging)
II. Treatment history
After synthesizing the head MRI, clinical manifestations, tongue diagnosis, and pulse, the patient was considered to have Yin deficiency as the basis and Dampness and Turbidity as the obstruction, resulting in clear Yang not ascending and Turbidity and Yin not descending, which is a heat evidence. Due to the prolonged progress of the disease, the patient was given Calamus Yujin Tang with addition and subtraction to resolve dampness and turbidity, clear heat and nourish yin, and on the basis of asking whether the patient had a history of levofloxacin allergy, the patient was given anti-infection treatment with the appropriate antibiotic piperacillin sodium tazobactam for injection.
III. Treatment effect
During the period of taking the above formula, the patient himself indicated that the abdominal pain was significantly relieved, the fever was reduced, and the flushing symptoms on both sides of the patient’s cheek were relieved on examination. After 7 days of hospitalization and taking the above formula, the patient indicated that the abdominal pain disappeared, there were no fever symptoms, and the feeling of consciousness and faintness was significantly relieved, considering that the patient’s diagnosis was clear and the effect was obvious, and the patient requested to be discharged with Chinese herbal medicine for conditioning, and no further imaging and laboratory tests were performed. In summary, the effect of combined Chinese and Western medicine treatment was relatively outstanding, the condition was controlled and the symptoms gradually disappeared.
IV. Notes
We are glad that the patient’s condition has been controlled after treatment, and all the indicators are improving. Keep warm to avoid catching cold leading to hyperthermia. In addition, patients should pay attention to blood glucose control, regular diabetic diet and oral hypoglycemic drugs after discharge from the hospital, and subsequently can take nourishing Yin and clearing fire tea or take Chinese herbal poultices for physical conditioning.
V. Personal insight
Fever in the elderly, especially in elderly female patients, is often characterized by Yin deficiency, especially in patients diagnosed with diabetes mellitus in Western medicine, often with Yin deficiency and internal heat as the root cause, coupled with the physiological structure of women, combined with urinary tract infections are more likely to occur, in the lower part of the damp-heat gonorrhea evidence, such as burning urine, abdominal pain and other manifestations, in the upper part of the damp stagnation in the middle Jiao, blocking the pathogenesis, resulting in lifting and lowering malfunction, can appear chest tightness At this time, on the basis of western medicine antibiotic treatment, the use of Chinese medicine formula treatment can greatly shorten the treatment period and achieve very good therapeutic effect, as in the case of this patient, after the combination of Chinese and western medicine treatment, the effect is remarkable.