中醫介入西醫感染症治療四肢水腫之病例報告

A Case Report of Bilateral Pleural Effusion and Limbs Edema with Zhen Wu Decoction

本病例為一76歲住院會診中醫的女病患，入院前半年患中耳炎，經西醫治療後，症狀稍改善，但呼吸道症狀仍持續，入院前一個月，反覆高燒約38°C，伴隨乾咳無痰、倦怠無力、微喘、下肢水腫等症狀，感染科診斷肺炎收入院治療，經西醫治療約一個月後，症狀仍無改善，於是在住院第28天會診中醫尋求協助。病人初診症狀喘症嚴重、四肢水腫3＋、全身倦怠無力、納差、小便頻、夜尿多、大便多次但量少、眠差易醒，實驗室檢查數據皆傾向於體內仍有嚴重發炎反應，肺部X光雙側肋膜積液嚴重。本病辨為心脾腎氣虛，兼有陰虛血熱證，治療方向以真武湯加減為主，搭配西醫常規治療利尿劑與白蛋白，加入中藥三天後效果明顯，一週後四肢水腫即消，體重下降約9公斤，其餘臨床症狀亦持續進步，此病例為一中醫介入西醫感染症，治療水腫的顯效案例，提供給臨床中醫師選方用藥上的參考。

A 76-year-old female without any past medical history had URI symptoms related to otitis media about 5 months. After treatment of antibiotics, her symptoms of otitis media were relieved. However, she still suffered from URI symptoms. In May 2018, she had a fever up to 38˚C, accompanied with dry cough, dyspnea, general weakness, and bilateral lower limbs edema. Three weeks later, she came to Taipei City Hospital, RenAi Branch for help where lab data revealed leukocytosis and elevation of AST, ALT which indicated a damage of liver function. Chest X-ray showed suspicious RLL pneumonia. Under the impression of fever, suspected otitis media or pneumonia, she was admitted for further evaluation and management. After admission, prophylactic antibiotics was given, but in vain. Three weeks later, she still had mild fever about 37.5°C, and her dyspnea and lower limb edema worsened. She also gained 6kg when compared with the first day of admission. Therefore, her family considered to consult Chinese medicine for integrated treatment with Western medicine. Therefore, we considered our plan of treatment and prescribed Zhen Wu Decoction, and monitored her clinical condition everyday. After giving this treatment for 4 days, her dyspnea relieved and extremities edema decreased. After one week of treatment, her overall condition improved.