基于证候演变中西医治疗老年难治性心力衰竭合并慢性肾功能不全1例
Integrated traditional Chinese medicine and western medicine treatment of senile refractory heart failure complicated with chronic renal insufficiency based on syndrome evolution: a case report
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1.北京中医药大学第三附属医院,心内科,北京 100029
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刘欣, 陈步星. 基于证候演变中西医治疗老年难治性心力衰竭合并慢性肾功能不全1例[DB/OL].(2023-02-27)[2023-11-05].http://cccl-tcm.cacm.org.cn/thesisDetails?columnId=26950607&Fpath=home&index=0
LIU Xin, CHEN Bu-xing. Integrated traditional Chinese medicine and western medicine treatment of senile refractory heart failure complicated with chronic renal insufficiency based on syndrome evolution: a case report[DB/OL].(2023-02-27)[2023-11-05].http://cccl-tcm.cacm.org.cn/thesisDetails?columnId=26950607&Fpath=home&index=0
刘欣, 陈步星. 基于证候演变中西医治疗老年难治性心力衰竭合并慢性肾功能不全1例[DB/OL].(2023-02-27)[2023-11-05].http://cccl-tcm.cacm.org.cn/thesisDetails?columnId=26950607&Fpath=home&index=0 DOI:
LIU Xin, CHEN Bu-xing. Integrated traditional Chinese medicine and western medicine treatment of senile refractory heart failure complicated with chronic renal insufficiency based on syndrome evolution: a case report[DB/OL].(2023-02-27)[2023-11-05].http://cccl-tcm.cacm.org.cn/thesisDetails?columnId=26950607&Fpath=home&index=0 DOI:
病史摘要,2,患者,女,76岁,主因“间断喘息憋气3月,加重1周”于2021年6月22日以“慢性心功能不全急性加重”收入我科。患者陈旧性心肌梗死病史,慢性心功能不全急性加重,慢性肾功能不全,入院后给予扩冠、利尿、抗血小板聚集等治疗,结合中医给予肺、脾、肾,上、中、下三焦清利湿热,通调水道,明显改善患者胸闷、痞满不食、小便不利等三焦症状,舌苔由积粉苔变为少苔,后期治以益气养阴,患者阴阳平和,诸证缓解,心肾功能改善,顺利出院。四诊信息 患者神清,精神差,喘息、憋气,时咯粉红色泡沫样痰,端坐呼吸,双下肢轻度水肿,时咳嗽、咳痰,咳少量黄粘痰,纳差,眠差,尿量少,舌黯红,积粉苔,脉细弱。中医诊断 心水病。中医病证 心水病,中医辨证:湿热内蕴,气阴两虚,痰瘀互结。中医治法 清利湿热,益气养阴,豁痰化瘀。西医诊断 1.慢性心功能不全急性加重;2.陈旧性前壁下壁心肌梗死;3.慢性肾脏病Ⅳ期。干预措施 西医主要给予抗血小板聚集、扩冠、利尿等治疗,中医根据证候演变治以清利湿热,益气养阴。疗效转归 患者心肾功能改善,顺利出院。
Summary of case history ,Patient, female, 76 years old, was admitted to our department on June 22, 2021 with "acute exacerbation of chronic cardiac insufficiency" mainly due to "intermittent wheezing and suffocation for 3 months, aggravating for 1 week". The patient has a history of old myocardial infarction, acute exacerbation of chronic cardiac insufficiency, and chronic renal insufficiency. After admission, western medicine was given such as coronary expansion, diuresis, and anti-platelet aggregation. Helping ",Sanjiao," to get rid of the "interior dampness-heat", can significantly improve the symptoms such as chest tightness, fullness, inability to eat, and difficulty urinating. The tongue coating changed from accumulating powdery coating to less coating. In the later stage, supplementing ,qi, and nourishing ,yin, was given. The patient's ,yin, and ,yang, were calmed, the symptoms were relieved, the heart and kidney function improved, and the patient was discharged smoothly.,Symptoms and signs ,The patient's expression and spirit were poor, wheezing, suffocation, sometime pink foamy sputum, orthopnea, mild edema of both lower extremities, frequent coughing, expectoration, coughing up a small amount of yellow sticky sputum, poor appetite, poor sleep, and low urine output. Dark red tongue, accumulated powder coating, thin and weak pulse.,TCM diagnosis ,Heart water disease.,TCM disease and syndrome ,Heart water disease, TCM syndrome differentiation: internal accumulation of dampness and heat, deficiency of both ,qi, and ,yin, phlegm and blood stasis.,TCM treatment ,Clears dampness and heat, replenishes ,qi, and nourishes ,yin, removes phlegm and removes blood stasis.,Western medicine diagnosis, 1. Acute exacerbation of chronic cardiac insufficiency; 2. Old anterior inferior myocardial infarction; 3. Chronic kidney disease, stage Ⅳ.,Interventions ,Western medicine mainly provides anti-platelet aggregation, coronary artery expansion, and diuresis. Traditional Chinese medicine treats according to the evolution of syndromes to clear dampness and heat, nourish ,qi, and ,yin,.,Clinical outcomes ,The patient's heart and kidney function improved and she was discharged successfully.
老年难治性心力衰竭慢性肾功能不全证候演变中西医结合治疗个案报道【适合阅读专业】 心血管科重症医学科急诊科老年科
Senile refractory heart failurechronic renal insufficiencysyndrome evolutionintegrated traditional Chinese and western medicine treatmentcase report【Suitable for reading majors】 Cardiovascular DepartmentIntensive Care UnitEmergency DepartmentGeriatrics
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