Summary of case history, Patient Sun , male, 26 years old, was diagnosed for the first time on October 27, 2020, with "swelling and pain in his left hand for 2 months". Two years ago, the physical examination found that serum uric acid was elevated, but without taking medicine. Gout developed in March 2020, and it was improved after oral administration of colchicine. In the past 2 months, the left hand was swollen, and the proximal interphalangeal joint of the left middle finger was tender.. Symptoms: left hand swollen, tenderness in the proximal interphalangeal joint of the left middle finger, dizziness, abdominal distention after eating, dry mouth, dry eyes, feeling that the limbs are sore and heavy, and tired. Naco, poor sleep, loose stools, once a day, yellow urine with a peculiar smell. Red tongue, yellow greasy coating, slippery pulse. Auxiliary examination: 2020-10-27 Biochemical: uric acid 592 umol/L, triglyceride 6.36 mmol/L, low-density lipoprotein cholesterol 3.98 mmol/L, no abnormality was found. Immediately measure blood pressure 145/90 mmHg.,TCM diagnosis ,Bizheng Gandanshirezheng,Western medicine diagnosis, 1. Gout;2. Hyperuricemia;3. Hyperlipidemia;4. Hypertension grade 1 (intermediate risk group);5. Fatty liver.,Therapeutic methods ,We gave him xiao chai hu tang and si miao san, the specific drugs were as follows: Bupleuri Radix 10 g,Scutellariae radix 10 g,Plantaginis herba 15 g,Coicis semen 30 g,Atractylodis rhizoma 10 g,Phellodendri Chinese cortex 10 g,Cyatjulae radix 15 g,Dioscoreae spongiosae rhizoma 15 g,Schisandrae Chinese fructus 10 g,Paeoniae radix alba 10 g,Citri sarcodactylis fructus 10 g,Chrysanthemi flos 15 g,Ziziphi spinosae semen 30 g,Lophatheri herba 10 g,Glycyrrhizae radix rhizoma 3 g. Western medicine treatment wasmainly to reduce the production of uric acid, and allopurinol was given orally at 2.5 mg Qd.,Clinical outcomes, Follow-up on November 5: Hand pain improved, no dizziness occurred, night sleep improved than before, and spirit improved. loose stools. Red tongue, slippery pulse. The original recipe added Smilacis glabrae rhizoma 10 g and Clematidis radix et rhizoma 10 g, 7 pieces, the dosage was the same as before. Follow-up consultation on November 19: The pain in the hand was completely relieved, dizziness did not occur, and the night sleep was fine. Recheck biochemistry: uric acid 403 umol/L, triglyceride 5.7 mmol/L, low-density lipoprotein cholesterol 2.03 mmol/L, add Dipsaci radix 15 g,Lysimachiae herba 15 g and Plantaginis herba 30 g, 14 doses, the dosage was the same as before. After taking the medicine, all the symptoms has been removed.
关键词
高尿酸血症痛风经验总结
Keywords
HyperuricemiaGoutExperience summary
references
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