Mr. Han, 36 years old

Visited Clinic on June 8, 2017

Diagnose: Proteinuria

Chief Complaint: Recurrent proteinuria

Present Medical History: The patient has history of lumbar disc herniation, urine routine showed urine protein (++), occult blood (++). The patient complains of lumbago, leg sore and distension, fatigue, pale complexion, slow and weak voice, big volume and foamy urine, a lot phlegm in the throat, mouth ulcer with thirsty but no desire to drink, aversion to cold, no sweating, poor appetite, full of dream.

Tongue and Pulse: Pale Tongue with white coat, pulse is slippery and soft.

TCM Diagnosis: Turbid urine

TCM Differentiation: Spleen-kidney deficiency, phlegm-turbidity obstruction

Treatment Principal: Strengthening spleen and warming kidney, consolidating essence and eliminating turbid.

Prescription:

The formula is for 7 days, herbs to be decocted in plain water, 3 times a day, take the decoction when it is warm.

Second visit on June 15: The volume of urine and foam decreased. Fatigue, lumbago, leg distending sore was relieved. Hands and feet are warm, not aversion to cold, thirsty and has bitter taste in the mouth. Tongue is light red with thin white fur; pulse is deep, slippery and soft.

Treatment: To modify the original prescription by subtracting xianmao, adding wumei 10g, to promote fluid production for suspending thirst, constraining qi and astringing essence. The formulae were for anther 21days.

Third visit: July 7: Urine Routine: occult blood (±) and proteinuria (±). All the symptoms were relieved. The last two formulae achieved good effect, so keep the same treatment principal and the formulae continues for another 14 days.

Forth visit: July 26: Foamy urine, hematuria were relieved significantly. The current symptoms included fatigue, short of strength, and body ache sometimes.

Treatment: Based on last formulae, subtract cang zhu, add huang qi 15g and bai zhu10g, to strengthen spleen and tonify deficiency, benefit and raise clear qi. After that, adjusted the prescription, continues another two months.

Follow up on October 5: Routine urine: proteinuria (-), occult blood (±).Tongue: light red with thin white coat; pulse: slippery and soft. After 1 month of Chinese medicine and 2 months of follow-up, urine has no more foam, proteinuria and hematuria were basically disappeared.

Notes: In “Plain Questions•Comprehensive Discourse on Phenomena Corresponding to Yin and Yang” It said: “If one over 40 years old, half of his body yin qi has already been consumed, daily activity and strength deteriorated”. The patient is on middle-aged, both yin and yang and body essence are insufficient; the spleen and kidney are malnourished. It TCM philosophy, “when there is a malnourishment, there will be pain." Yang deficiency makes damp and cold coagulate in the lumbar house, joints and meridians, man become aversion to cold, which is called "when there is stoppage, there is pain", results in lumbago, legs distending pain and sore.

Cold and turbid phlegm stagnated for long time impaired kidney collaterals, causes body essence and blood flows out of the vessels. Long term sickness destroyed body Yang Qi, weaken the function of spleen and kidney, become inability to secure and contain body essence. Therefore, it is difficult to controlled proteinuria and hematuria. It leads to big volume of urine, fatigued, low spirit and short of strength, lumbago and distending pain and sore.

Yang deficiency makes dysfunction of water and dampness transportation, thus phlegm and turbidity are generated internally, and accumulated in the throat. Exuberant cold stay in the lower Jiao forces the true yang in kan to deviate from its original position and take to upper position. It called water-cold and dragon flies, deficient yang floats out of its origin. It manifested as mouth ulcers, thirsty and other empty fire symptoms.

In first visit, we used heavy dose of shan yao, qian shi, cang zhu, to sthrenthen spleen and secure root, invigorate the spleen, dissolve dampness; Those herbs Yin yang huo, xianmao, xian he cao, lujiaoshuang, baji tian, and du zhong are to warm Yang and promote Qi movement, boost kidney and supplement essence, and strengthen back and knees; Jiu yurou, wuweizi, andjinyingzi stop leakage and secure the essence, warm kidney and concentrate urine; Paojiang and puhuangtan warm the kidney and astringe, stop bleeding; Because there is internal stoppage of phlegm and water- dampness, so use yu mi xu to separate clear and excrete turbid, dissolve dampness and promote urination; Mu hu die clear and benefit throat, and disperse phlegm and tonify deficiency.

Second Visit: The patient complains dry and bitter taste in the mouth; lumbago and leg distending pain and sore were relieved. The foamy urine is decreased. We modified the original prescription by subtracting xianmao, which is acrid, hot and dry; to prevent from damaging Yin liquid; adding wumei to promote fluid production, stop thirst; use sour flavor herb to contract and astringe essence, harmonize cold and heat.

Fourth visit: Patient still has symptoms as fatigue, low spirit and short of strength, and the other symptoms were relieved. In case of Qi consumption and body liquid impairment, Doctor modified last prescription by subtracting cangzhu, which is mobile but not stay, and add huang qi and baizhu to strengthen spleen and invigorate Qi; use gancao to suppress fire, tonify earth, co-govern middle Jiao and protect center Qi. With the comprehensive formulae, the deficiency can be filled, the cold can be dispersed, the turbidity can be removed, and the heat can be eliminated.

It must put in mind that in case of recurrence, after proteinuria to be controlled, patient must continue the treatment for another couple of weeks.