Summary of case history

　PU

female

59 years old

consulted for "cough with shortness of breath after activity for more than 1 month

aggravated for 1 day". The patient had a dry cough after a cold spell more than a month ago

and felt slightly better after taking oral medications (details unknown). But 2 days later

no obvious cause of diarrhea

7~8 times / day

with cough

shortness of breath

self-assessment of the new coronavirus antigen-positive

no fever

chills

no hemoptysis

chest pain

no nausea

vomiting and other discomforts

emergency treatment of Fuzhou City

a tertiary hospital

to the CT scanning of the chest showed that: bilateral viral pneumonia

a small amount of bilateral pleural effusion. The patient was diagnosed with "pneumonia and COVID-19 infection"

and was given Shupu Shen anti-infection and Methylprednisolone anti-inflammatory treatments. His condition deteriorated and he developed respiratory failure

and was transferred to ICU with "severe pneumonia". He was transferred to ICU

and was successively given non-invasive ventilator-assisted respiration (January 7

2023 to January 25

2023)

high-flow oxygen (January 25

2023 to January 31

2023)

nirmatrelvir/ritonavir antiviral treatment

methylprednisolone (January 5

2023 to January 16

2023) anti-inflammatory treatment

sulphenesin (January 5

2023 to January 13

2023)

meropenem (January 13

2023 to February 1

2023)

caspofungin (January 16

2023 to February 1

2023) anti-infective treatment

ambroxol to reduce phlegm

and anticoagulation with low molecular heparin.After 30 days of treatment

the condition improved

and the partial pressure of oxygen in the rechecked blood gases was 84.1 mmHg

and she was discharged from the hospital on February 4

2023. 1 day ago

the symptoms of shortness of breath were aggravated

and the oxygen saturation level was 92% measured by pulse

oximeter at home

so she visited the outpatient clinic of our hospital. Current symptoms: cough

yellow sputum

chest tightness

accompanied by shortness of breath

fatigue

dry mouth

nausea

sleep

bowel movement. The tongue was red

the moss was yellow and greasy

and the pulse was fine.

TCM diagnosis

　Dyspnea disease(deficiency of Qi and Yin

phlegm and heat around the lungs and evidence of blood stasis).

Western medicine diagnosis

　Convalescence period of severe pneumonia (COVID-19).

Therapeutic methods

　For traditional Chinese medicine (TCM) treatment

the " Jing Shen Wu Wei Formula" created by Professor CHAO Enxiang is selected as the basic formula

with the basic treatment method of invigorating Qi and nourishing Yin

dispel heat and transform phlegm

invigorate blood circulation and eliminate blood stasis combined with the symptoms of patients

dialectical treatment.

Clinical outcomes

　After 1 month of TCM treatment

the patient's symptoms of chest tightness and shortness of breath improved significantly

and the oxygen saturation level recovered to more than 95%. Chest CT shows the diffuse interstitial lesions in the lungs

in order to avoid the residual fibrosis

the patient continued to be treated by TCM for 2 months

and then he was rechecked by chest CT in

Second Affiliated Hospital of Fujian University of Traditional Chinese Medicine

on May 3

2023

and the lesions were basically absorbed.