1. Summary of medical history Female, 64 years old. She was admitted to the hospital on March 20, 2004 with the main reason of “edema of both lower limbs for more than 1 year”. The patient developed bilateral lower limb edema 1 year ago without any obvious cause, which was not taken seriously and was not treated. In order to clarify the diagnosis and further treatment, he came to our hospital on March 15, 2004, and was diagnosed as “acute nephritis”, treated with penicillin, etc., but the edema did not significantly relieve, and later intermittently treated with oral Chinese medicine, the edema of both lower limbs was sometimes light and sometimes heavy. The patient was diagnosed with “nephrotic syndrome” and admitted to hospital. At the time of admission, the symptoms were: concave edema of both lower limbs, lumbago, fatigue, dry mouth, bitter mouth, poor appetite, yellow urine and normal stool. He was physically fit and had no history of diabetes mellitus. He had no swelling of the eyelids, light red throat, no enlargement of the tonsils, small heart borders, clear breath sounds in both lungs, soft abdomen, no detectable liver or spleen, percussion pain in both kidney areas (±), concave edema in both lower limbs, neurophysiological reflexes were present, no pathological reflexes were elicited. The tongue is dark red, the coating is slightly yellow and greasy, and the pulse is thin and smooth and slightly counted. Laboratory examination: blood RBC 3.19×1012/L, WBC 4.8×109/L, HGB103g/L, N0.57, L0.36. urine protein ++++, red blood cells 2~3/high magnification field, 24-hour urine protein quantification 6.27g. blood creatinine 74µmmol/L, creatinine clearance 72.5ml/min. Urea nitrogen 5.3mmol/L. Serum total protein 38g/L, albumin 17g/L, total cholesterol 10.0mmol/L, triglycerides 1.93mmol/L, calcium 2.1mmol/L, phosphorus 1.43mmol/L, bicarbonate 26mmol/L. HBsAg(-), glutamic aminotransferase 6U/L, glutamic aminotransferase 15U/L. Blood and urine protein fixed electrophoresis, serum immunoglobulin, ANA, ENA antibody profile and serum complement were normal. Ultrasound of both kidneys: right kidney 10.1×3.1×3.5cm, cortical thickness 0.9cm, left kidney 10.4×4.0×4.2cm, cortical thickness 1.3cm. electrocardiogram was normal. Admission diagnosis: chronic glomerulonephritis, nephrotic syndrome, renal hypertension. Treatment: After admission, 1 dose of Chinese medicine was given to benefit Qi and nourish Yin, clear heat and dampness. Prescription: Astragalus membranaceus 30g, Radix et Rhizoma Polygonati 30g, Radix et Rhizoma Dioscorea 12g, Dampness 12g, Cornu Cervi Pantotrichum 12g, Poria Cocos 12g, Rhizoma Zeligii 12g, Radix et Rhizoma Quasi-Shamnus 12g, Radix et Rhizoma Zhi Mu 12g, Radix et Rhizoma Phellodendron 12g, Plantago lanceolata 30g. Light microscopy: renal puncture tissue showed 24 glomeruli, 1 spherical sclerosis, diffuse thickening of the basement membrane of the remaining glomeruli, segmental peg formation, and subepithelial eosinophilic deposition. The renal tubular epithelium was heavily vacuolated and degenerated, with focal disintegration and regeneration. Mild interstitial edema with focal lymphatic and mononuclear cell infiltration. Small arterial wall thickening. Immunofluorescence: IgG+++, IgA-, IgM+, C3++, C1q-, FRA+, Alb-. Electron microscopy: intermittent peg-like thickening of GBM with electron-dense material deposition visible between pegs and extensive fusion of epithelial cell peduncles. Combined with light microscopy, electron microscopy and immunofluorescence examination, the renal pathology was diagnosed as stage II membranous nephropathy. Based on the clinical and pathological findings, a case discussion was held on April 2, 2004 to decide the next treatment plan. 2. Discussion of medical history: The patient’s main clinical manifestation was swelling of both lower limbs, so the diagnosis of Chinese medicine was “edema”. The onset of edema was slow, and the duration of the disease was more than one year. There was no superficial, heat or actual evidence such as irritable fever, thirst, red urine and constipation, so it belonged to the category of “Yin water” in Chinese medicine. Edema should be clinically distinguished from drinking and phlegm, and it is generally believed that thick and turbid is phlegm, clear and thin is drinking, and clearer is water. From the analysis of Chinese medicine, the patient’s waist is sore, weakness, and thin pulse, which is due to deficiency of kidney qi, deficiency of kidney qi, lack of power of bladder qi-chemistry, and internal stagnation of water-dampness, thus edema; water-dampness is prolonged, depressed and feverish, so we see symptoms of damp-heat such as bitter mouth, yellow urine, yellow tongue coating, and slippery pulse; damp-heat consumes yin, so we see symptoms of kidney-yin deficiency such as dry mouth and red tongue. Therefore, Chinese medicine identifies this as a deficiency of both kidney qi and yin, with internal damp-heat. It should be noted that the patient’s tongue is dark red, which indicates the presence of blood stasis in the body. Can the original formula include products that invigorate blood circulation and resolve blood stasis such as peach kernel and safflower? Resident physician Zhao Yu: summarizes the clinical features of the patient: elderly female, edema as the main clinical manifestation, and renal pathology diagnosis of stage II membranous nephropathy. The current clinical and pathological diagnosis is clear, and the next step of treatment is now mainly discussed. From the perspective of modern medicine, stage II membranous nephropathy, if edema is obvious and urine protein is high, standard course of hormone and immunosuppressant treatment can be used, and on this basis, oral administration of Chinese medicine can be used to reduce toxicity and increase effectiveness. Regarding the diagnosis and treatment of TCM, we agree with Dr. Deng Jun’s diagnosis of “Yin Shui”. This disease belongs to the category of miscellaneous diseases of internal injuries in TCM, so the method of identification often adopts the identification of internal organs; because of the long duration of the disease, the clinical manifestation is mostly the evidence of deficiency at the origin and the symptoms. The present patient’s deficiency is manifested as Qi and Yin deficiency, and the symptomatic deficiency is manifested as dampness and stagnation, so the treatment should benefit Qi and nourish Yin, clear heat and dampness, and activate blood and water. Dr. Deng Jun suggested adding peach kernel and safflower to invigorate blood circulation and resolve stasis, because peach kernel and safflower are too warm and dry, which can easily injure fluid. It may be more appropriate to add some herbs that invigorate blood and promote water, such as Ze Lan, Yimou Cao, and Pierced Mountain Dragon. The diagnosis of nephrotic syndrome does not need to be confined to the “three highs and one low”, i.e. high swelling, massive proteinuria, hyperlipidemia and hypoproteinemia, but it is generally believed that as long as there is “one high and one low”, i.e. massive proteinuria and hypoproteinemia The diagnosis can be confirmed by the presence of “one high and one low”, i.e. massive proteinuria and hypoproteinemia. The patient’s 24-hour urine protein quantification was 6.27g and serum albumin was 17g/L, so the clinical diagnosis of nephrotic syndrome could be made; through renal puncture biopsy, the pathological diagnosis was stage II membranous nephropathy, and the renal function was normal. (2) Treatment: According to the domestic treatment recommendations for primary membranous nephropathy: urine protein.