中医审因、审机论治系统性红斑狼疮一例
A Case of Treating Systemic Lupus Erythematosus by Examining Cause and Mechanism of Traditional Chinese Medicine
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1.山东中医药大学附属医院风湿免疫科,济南 250014
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孙雨,刘英.中医审因、审机论治系统性红斑狼疮一例[DB/OL].(2023-11-13)[2023-11-13].http://cccl-tcm.cacm.org.cn/thesisDetails?columnId=43867468&Fpath=home&index=0&lang=zh
SUN Yu,LIU Ying.A Case of Treating Systemic Lupus Erythematosus by Examining Cause and Mechanism of Traditional Chinese Medicine[J].,
孙雨,刘英.中医审因、审机论治系统性红斑狼疮一例[DB/OL].(2023-11-13)[2023-11-13].http://cccl-tcm.cacm.org.cn/thesisDetails?columnId=43867468&Fpath=home&index=0&lang=zh DOI:
SUN Yu,LIU Ying.A Case of Treating Systemic Lupus Erythematosus by Examining Cause and Mechanism of Traditional Chinese Medicine[J]., DOI:.
病史摘要,2,患者张某,女,21岁,2023年7月16日因“面部红斑10年,水肿头晕1周”来诊。患者10年前因日晒后出现面部红斑,于外院诊为“系统性红斑狼疮”,予激素、羟氯喹治疗好转。5年前曾病情反复药物加量。1周前患者无诱因出现水肿头晕,入住我科。四诊信息:患者精神欠佳,情绪焦虑,颜面、下肢水肿,面部红斑,时有头晕天旋地转感,心慌,胸闷,脱发,腹胀,纳差,眠可,小便量偏少、有泡沫,大便调。语声低,气息平,舌红、苔白,脉沉。中医诊断 蝶疮流注(脾肾亏虚,水湿泛滥,瘀热互结)。西医诊断 系统性红斑狼疮,狼疮性肾炎,肾病综合征,狼疮性脑病,肺炎,腹腔积液,胸腔积液,心包积液,低蛋白血症,甲状腺功能减退症,电解质紊乱,贫血。干预措施 西医予甲强龙、吗替麦考酚酯胶囊抑制免疫,补充蛋白、利尿、抗凝等对症处理。中医审机论治阶段,以补肾健脾利湿,清热解毒活血为治则,方选六味地黄丸加减;中医审机论治阶段,以健脾化痰,清热化瘀,方选半夏白术天麻汤合菖蒲郁金汤、栀子豉汤加减。疗效转归 疗效评定:显效。转归:好转。
Summary of case history, The patient, surnamed Zhang, female, 21 years old, came to see the doctor on July 16, 2023 due to "facial erythema for 10 years, edema and dizziness for 1 week". The patient was diagnosed as "systemic lupus erythematosus" 10 years ago due to facial erythema after sun exposure, and was treated with hormone and hydroxychloroquine for improvement. Five years ago, he had repeated drug increases because of relapse. The patient was admitted to our department one week ago with edema and dizziness without cause. Four diagnostic information: the patient is mentally ill, emotional anxiety, edema of the face and lower limbs, facial erythematosis, dizziness and spinning feeling, palpitation, chest tightness, hair loss, abdominal distension, poor appetite, sleep, urine volume is less, foam, stool adjustment. The voice is low, the breath is flat, the tongue is red, the fur is white, the pulse is heavy.,TCM diagnosis, Sphenoid ulcer streaming (spleen and kidney deficiency, water flooding, blood stasis and heat interjunction),Western medicine diagnosis, Systemic lupus erythematosus, lupus nephritis, nephrotic syndrome, lupus encephalopathy, pneumonia, peritoneal effusion, pleural effusion, pericardial effusion, hypoproteinemia, hypothyroidism, electrolyte disorders, anemia.,Therapeutic methods, Western medicine gives meprednone, mycophenol ester capsules to suppress immunity, supplement protein, diuretic, anticoagulation and other symptomatic treatment. At the stage of TCM examination and treatment, to tonifying kidney and invigorating spleen and dampness, clearing heat and detoxifying activating blood as the treatment principle, the formula was chosen to add or reduce Liuwei Dihuang pills; In the stage of TCM examination and treatment, to strengthen spleen and dissipate phlegm, clear heat and remove blood stasis, the prescription selected Banxia Baizhu Tianma Decoction combined with Acorus Yu Jin decoction and gardenia tempeh decoction.,Clinical outcomes, Evaluation of curative effect: obvious effect. Outcome: Improved.
系统性红斑狼疮审因论治审机论治
Systemic lupus erythematosusDifferentiation and treatment based on etiologyDifferentiation and treatment based on pathogenesis
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