何晓瑾辨治干燥综合征合并胃食管反流病验案一则
Treatment of Sjogren's Syndrome Complicated with Gastroesophageal Reflux Disease Differentiated by HE Xiaojin: A Case Report
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1.南京中医药大学附属医院&江苏省中医院风湿科,南京 210029
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刘洁, 何晓瑾. 何晓瑾辨治干燥综合征合并胃食管反流病验案一则[DB/OL].(2023-10-11)[2023-11-05].http://cccl-tcm.cacm.org.cn/thesisDetails?columnId=42812338&Fpath=home&index=0
LIU Jie, HE Xiaojin. Treatment of Sjogren's Syndrome Complicated with Gastroesophageal Reflux Disease Differentiated by HE Xiaojin: A Case Report[DB/OL].(2023-10-11)[2023-11-05].http://cccl-tcm.cacm.org.cn/thesisDetails?columnId=42812338&Fpath=home&index=0
刘洁, 何晓瑾. 何晓瑾辨治干燥综合征合并胃食管反流病验案一则[DB/OL].(2023-10-11)[2023-11-05].http://cccl-tcm.cacm.org.cn/thesisDetails?columnId=42812338&Fpath=home&index=0 DOI:
LIU Jie, HE Xiaojin. Treatment of Sjogren's Syndrome Complicated with Gastroesophageal Reflux Disease Differentiated by HE Xiaojin: A Case Report[DB/OL].(2023-10-11)[2023-11-05].http://cccl-tcm.cacm.org.cn/thesisDetails?columnId=42812338&Fpath=home&index=0 DOI:
病史摘要,2,患者毛某,女性,57岁。2021年11月4日因“口眼干燥6年余,伴上腹部不适间作2年”就诊。2015年患者无明显诱因出现口干眼干、咳嗽咳痰,于江苏省中医院诊断为“干燥综合征合并间质性肺病”。近2年来频繁出现反酸、烧心等上腹部不适症状,遂来我院就诊。四诊信息:患者腹胀时作,反酸,有烧心感,饮食稍有不慎即加重。晨起咳黏痰,口干眼干,纳食偏少,手指皮肤干燥。大便1次/日、质偏干,小便调,夜寐尚安。舌暗有细裂纹、苔薄黄,脉细。中医诊断 燥痹(肺脾亏虚、阴虚络阻证)。西医诊断 干燥综合征;间质性肺病;胃食管反流病。干预措施 中医治疗以健脾益肺,养阴通络为法,予自拟健脾润燥通络方加减治疗。疗效转归 临床缓解。
Summary of case history, Patient Mao, female, 57 years old. On November 4, 2021, he sought medical attention due to "dry mouth and eyes for more than 6 years, accompanied by discomfort in the upper abdomen for 2 years". In 2015, the patient had no obvious causes of dry mouth, dry eyes, cough, and phlegm, and was diagnosed with "Sjogren's syndrome combined with interstitial lung disease" at Jiangsu Provincial Traditional Chinese Medicine Hospital. In the past two years, there have been frequent symptoms of upper abdominal discomfort such as acid reflux and heartburn, so I came to our hospital for treatment. Symptoms and signs: When the patient has abdominal distension, they may experience acid reflux, heartburn, and even worsen if there is slight carelessness in their diet. In the morning, I cough and have sticky phlegm, dry mouth and eyes, less food intake, and dry skin on my fingers. Stool once a day, dry in quality, with regular urination and a peaceful night's sleep. The tongue has small cracks, thin yellow fur, and thin veins.,TCM diagnosis, dry bi (lung and spleen deficiency, yin deficiency and collateral obstruction syndrome).,Western medicine diagnosis, sjogren's syndrome; interstitial lung disease; gastroesophageal reflux disease.,Therapeutic methods, traditional Chinese medicine treatment is based on the principles of strengthening the spleen and lungs, nourishing yin and unblocking collaterals, and is treated with a modified formula for nourishing the spleen, moistening dryness, and unblocking collaterals.,Clinical outcomes, clinical remission.
燥痹干燥综合征间质性肺病胃食管反流病
dry bisjogren's syndromeinterstitial lung diseasegastroesophageal reflux disease
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