中西医结合治疗多系统萎缩案
Treatment of Multiple System Atrophy with Integrated Traditional Chinese and Western Medicine
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1.河南中医药大学第三附属医院康复科,郑州 450008
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左刚, 杨云涛, 郑瑞芳. 中西医结合治疗多系统萎缩案[DB/OL].(2023-10-26)[2023-11-05].http://cccl-tcm.cacm.org.cn/thesisDetails?columnId=43052889&Fpath=home&index=0
ZUO Gang, YANG Yuntao, ZHENG Ruifang. Treatment of Multiple System Atrophy with Integrated Traditional Chinese and Western Medicine[DB/OL].(2023-10-26)[2023-11-05].http://cccl-tcm.cacm.org.cn/thesisDetails?columnId=43052889&Fpath=home&index=0
左刚, 杨云涛, 郑瑞芳. 中西医结合治疗多系统萎缩案[DB/OL].(2023-10-26)[2023-11-05].http://cccl-tcm.cacm.org.cn/thesisDetails?columnId=43052889&Fpath=home&index=0 DOI:
ZUO Gang, YANG Yuntao, ZHENG Ruifang. Treatment of Multiple System Atrophy with Integrated Traditional Chinese and Western Medicine[DB/OL].(2023-10-26)[2023-11-05].http://cccl-tcm.cacm.org.cn/thesisDetails?columnId=43052889&Fpath=home&index=0 DOI:
病史摘要,2,患者,男,60岁,头晕伴双下肢无力4年,加重1月余。症见:头晕,头懵,视物模糊,言语语速慢,写字困难,双手持物震颤,双下肢无力,行走不稳,自汗,尤以后头部、项部明显,甚如水洗,颈部活动受限,转侧不利,纳眠可,小便偏黄,大便难,4日一行,舌淡红、苔薄黄,脉浮弱。查体:双手静止性震颤,共济失调步态,双侧下肢肌力Ⅳ级+,双下肢肌张力高,双侧指鼻试验可,跟膝胫试验不稳准。卧位血压110/70 mmHg,坐位血压110/60 mmHg,立位血压88/55 mmHg。辅助检查头颅磁共振示:小脑萎缩;桥脑萎缩(河南省人民医院,2019年2月)。中医诊断 骨繇(本虚标实证;肾精亏虚,上焦风热证)西医诊断 多系统萎缩干预措施 行中西医结合治疗。中医予中药、针刺、艾灸综合治疗。中药予桑菊饮合玉屏风散加减以疏风清热,固表止汗。症状减轻后,以杞菊地黄丸合玉屏风散以益精填髓,扶正固本。同时头针、体针并用以通督调神,祛邪通络,配合督灸以益肾通督。西医给予口服普拉克索药物治疗,同时配合平衡训练,下肢运动功能训练,连续治疗1月余。疗效转归 头晕发作次数较前明显下降,仅在活动时偶发。四肢较前有力,可自行行走。双手震颤较前缓解,可进行书写。
Summary of case history, A 50-year-old male patient presented with dizziness and weakness of lower limbs for 4 years, which worsened for more than 1 month. Disease see: dizziness, head of meng, blurred vision, the words are too slow, writing is difficult, tremor, with both hands double lower limbs weakness, walking instability, spontaneous perspiration, especially after the head, an obvious, such as water washing, limited neck activity, turn adverse side, he sleeps, urine yellow, hard stool, 4th line, tongue reddish, moss thin yellow, floating pulse is weak. Physical examination: static tremor of both hands, ataxia gait, bilateral lower extremity muscle strength grade ⅳ+, bilateral lower extremity muscle tension, bilateral finger to nose test, heel knee tibial test instability. The blood pressure was 110/70 MMHG in the supine position, 110/60 MMHG in the sitting position, and 88/55 MMHG in the standing position. Auxiliary examination: Brain magnetic resonance imaging showed cerebellar atrophy; The pons atrophy. (Henan Provincial People's Hospital, February 2019),TCM diagnosis, guyao disorder(deficiency standard: kidney essence deficiency, heat syndrome of upper coke wind),Western medicine diagnosis, multiple system atrophy,Therapeutic methods, Integrated traditional Chinese and Western medicine treatment. Traditional Chinese medicine, acupuncture, moxibustion comprehensive treatment. Traditional Chinese medicine to Sangjuyin and Yupingfeng San;. powder addition and reduction to wind clearing heat, strengthening exterior and reducing sweat. After symptom is alleviated, with Qijudihuang bolus unites jade screen dispersing to replenish the essence and fill the marrow, supporting the healthy energy. At the same time, the head needle and the body needle are used to unblocked governor meridian Tiao Sprit, remove evil and dredging the meridian, and cooperate with Du moxibustion to benefit the kidney and dredging the meridian Western medicine gave oral pramipexole drug treatment, combined with balance training, lower limb motor function training, continuous treatment for more than one month.,Clinical outcomes, the number of dizziness episodes decreased significantly compared with before, and only happened occasionally during activities. The limbs are stronger than the front and can walk by themselves. The tremor of both hands is relieved and can be written.
多系统萎缩中西医结合祛邪通络益精填髓
multiple system atrophyintegrated traditional Chinese and western medicineremove evil and remove collateralsreplenish the essence and fill the marrow
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