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International Journal of Clinical Case Reports 2014, Vol. 4, No. 3, 1-4
http://ijccr.biopublisher.ca
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slow or arrest structural joint damage. Drug therapy
for RA has evolved from salicylates, to NSAIDs, CSs,
DMARDs, MTX, and finally to biologic response
modifiers (Katherine and Jonathan, 2012).
Case
Patient, Male, 56 years old, in March 2005, was
discovered to have an incomplete right ventricular
conduction block after visiting the hospital, who
complained of chest tightness after a strenuous work.
The patient’s treatment following admission was seen
some improvements, and then he was discharged.
After leaving the hospital, he had shoulder and back
pains, with a body temperature at 36.7. All the
examination reports did not show anything abnormal.
Previous medical history showed that the patient had
neutropenia, and he felt repeated pains on both knees
after strenuous work, general body weakness, and
feeling of over-burden. Others: Frequent stools, pale
tongue, white and moistness coating, deep pulse.
When he came in at 2005-6-10, he was diagnosed with
Bi syndrome of liver and kidney deficiency with wind
damp blockage in the channels. Principles of
Treatment: Nourishing kidney and regulating liver to
invigorate tendon, resolving dampness to dredging
collaterals. Prescriptions: Pubescent Angelica Root,
Chinese taxillus herb, Large Gentain Root,
Ledebouriella Root, Chinese Angelica Root, Cooked
Rehmannia Root, Eucommia Bark, Astragalus, Pollen
Typhas, Hyacinth Bean, Chinese Quince Fruit (Each
medicine is 10 grams and 7 prescription). Perform
them regularly and change treatments accordingly, the
following formulae were the same.
Disease condition showed significant improvement
after treatment for five months. However, in
November 10, 2005, the change in weather
characterised by the drop in temperature during the
fall caused the patient to feel increased pain on both
knees, he suffered transient tinnitus hearing loss
occasionally. Others: appetite, sleep, urine and stool
did not show anything abnormal, red tongue, white
coating, and fine pulse. Diagnose: The syndrome of
deficiency of liver and kidney with phlegm-blood
stasis obstructing the channel and damp syndrome due
to spleen deficiency. Accordingly, strengthen the drugs
with the functions of invigorating spleen to remove
dampness, removing blood stasis and dredging
collaterals. Prescription: Astragalus 30G; Codonopsis
Root, Cornus Fruit, Medlar, Ledebouriella Root,
Cyathula Root, Achyranthis Bidentatae, Mulberry
Twig, Cassia Twig, Adlay, and Cooked Rehmannia
Root 10G; Gambir Vine Stems and Thorns, Large
Gentain Root, and Sinomenium acutum 20G;
Frankincense, Myrrh, and Licorice Root 6G, (7
prescription).
He continued receiving these
medications and treatments for a period of 16 months
during which his conditions were stable and necessary
adjustments were made based on his symptoms.
Because he went abroad for work reasons, the patient
stopped receiving treatments and medications for a
period of one year.
As soon as he got back, he came in for a check-up
with complains of stiffness of the right middle finger
which he could not flex and was worse in the
mornings after sleep, with pains on both heels and
increased sweatings on both palms and soles of his
feet, cold sweating after work or exercise, dryness of
the pharynx even at rest, fine pulse, others are normal.
Diagnose: Cold damp syndrome with insufficiency of
liver and kidney. Principles of treatment are
nourishing-kidney, regulating-liver, invigorating-tendon
and warming-Meridian.
Prescription:
Cooked
Rehmannia Root, Cornus Fruit, fructus psoraleae,
semen cuscutae, Chinese Angelica Root, and
Szechuan Lovage Root 10G; White Peony Root and
cuttle-bone 15G; Asarum sieboldi Mig, lignum
millettiae, and cinnamon 30G; Cassia Twig 5G (7
prescription); Cinnamom-Poria Bolus, Eight at a time,
three times a day. After treatment, there were
significant improvements in his symptoms, but he still
felt dull pain on both of his heels, and slightly
abnormal sensation on the right middle finger, he
maintained a normal appetite and sleeping condition,
pulse was fine and wiry. The condition had occasional
relapses during the two years treatment of nourishing
liver and kidney, Tong bi, and relaxing tendons as well
as collaterals. He visited our hospital on February 27,
2010 when he had mild systemic joint pain, slight
sweating, normal sleep and appetite, fine pulse.
Diagnose: The syndrome of deficiency of liver and