Ankylosing spondylitis test case

  Wang, female, 34 years old, from Zhejiang.  Her complaint: low back pain for three years, aggravated for ten days. history: the patient had a history of low back pain 2-3 years ago. pain at the hip-lumbosacral area around February, gradually moved upward, relieved by itself after local physiotherapy and Chinese medicine. This time, the pain at the posterior hip increased again 10 days ago, especially in the morning when he first woke up. 2007.5.12, Zhoushan, ASO(-), RF(-), CRP 49.9mg/dl, ESR 24mm/h, HLA-B27(+), blood WBC 6.5, HB 124g/dl, N54. 3%, PLT 177. 3%, PLT177. The pelvic radiograph showed “left sacroiliac arthritis”. The diagnosis was “AS”. Given Norfloxacin and Chinese herbal medicine treatment. The lower lumbosacral pain was obvious when standing or walking, accompanied by posterior lumbar hip discomfort. The nasal pain is acceptable, the urine is regulated, and the stool is one line for 2-3 days. Morning stiffness of the joints, limited to get up. She feels that her middle and upper abdomen is distended and painful when she eats carelessly, but no definite diagnosis has been made. The coating is yellow and greasy, and the pulse is thin.  Diagnosis: spinal paralysis (kidney deficiency and coldness in the spine, phlegm and stasis blocking the ligament).  Treatment is to tonify the kidney and disperse cold, resolve phlegm and clear the ligaments.  Prescription: Dou Shu 12g, Sang Sang 30g, Di Tortoise 12g, Atractylodis Macrocephalae 12g, Atractylodis Macrocephalae 15g, Chen Pi 9g, Semen 9g, Tu Fu Ling 12g, Yan Hu Suo 30g, Hu Zhi 30g, Fusarium 30g, Ginseng San Qi 6g, Chuan Xiong 9g, Chuan Zong 15g, Cistanches 15g, Dried Ginger 6g, The patient complained of significant symptom relief, smooth stool, 1-2 lines a day, occasional discomfort in the stomach and epigastrium, light red tongue with thin greasy coating, weak pulse.  The above formula was supplemented with 30g of Dog’s spine, 15g of Bonesetter, 9g of Buddha’s hand, and 9g of Nine Fragrant Worms. The patient no longer had obvious symptoms, and the blood sedimentation and CRP were not abnormal during the recheck.