Ms. Zhao, 38 years old, had frequent urination, urgent urination, urinary pain, urethral burning sensation, yellow and red urine, heavy vaginal discharge, irregular menstruation, fever, chills, back pain, but no swelling. She went to the hospital for examination and was diagnosed with urinary tract infection. After 2 weeks of oral norfloxacin treatment, the fever and chills were gone, but she still had frequent urination, urinary pain, and lower abdominal stabbing pain, which radiated to the lumbosacral region. There was a mass in the lower abdomen, which was painful when pressed, so she sought treatment from a traditional Chinese medicine doctor. Examination: frequent urination, painful urination, burning sensation in the urethra, yellow and red urine, dull pain in the waist, heavy vaginal discharge, dry mouth and thirst. Physical examination: poor spirit, rosy complexion, dark tongue with petechiae, thin white fur, stringy and thin pulse. Diagnosed as pelvic inflammatory disease, treatment should be heat-clearing, dampness-removing and stranguria-relieving, Zhuling Decoction plus or minus. Prescription: Poria, Poria, Alisma, Talc, Imperata Root, Dianthus Superbus, Hedyotis Diffusa, Taraxacum, Pyrrosia, Akebia, Platycladus orientalis charcoal, Sanguisorba officinalis charcoal. Decoction in water, 1 dose per day. After taking 15 doses of the above prescription, Ms. Zhao was re-examined: her frequent urination, urgent urination, and painful urination symptoms were significantly improved, and her leucorrhea was normal, but her waist was still sore and there was still a mass in her abdomen. She continued to take the original prescription and was advised to drink more water and avoid fatty, sweet, and spicy foods. After taking 15 doses again, the third diagnosis: menstruation came as expected, the symptoms of low back pain disappeared. In order to consolidate the therapeutic effect, the patient continued to take 7 doses of the medicine. The fourth diagnosis: all symptoms disappeared, leucorrhea was normal, and the abdominal mass disappeared. |
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