[Case study] One case of lower limb edema in a 72-year-old lady

Patient: Female, 72 years old

Chief Complaint: Bilateral lower limb edema for several months, morning stiffness in hands, no other obvious discomfort. Tongue presentation: Triangle-shaped, pale with a white coating.

Diagnosis and Analysis: The patient, being elderly and constitutionally weak, presented with symptoms of bilateral lower limb edema and morning stiffness in the hands, indicative of deficient kidney qi in traditional Chinese medicine (TCM). According to TCM theory, the kidneys govern water metabolism, and a deficiency in kidney qi can lead to imbalances in fluid metabolism, resulting in symptoms such as edema.

Treatment Plan: Modified Ji Sheng Kidney Qi Pill

Prescription: Shu Di Huang (Rehmannia Root) 15g, Shan Yao (Chinese Yam) 30g, Shan Zhu Yu (Cornus Fruit) 30g, Ze Xie (Water Plantain Rhizome) 15g, Fu Ling (Poria) 30g, Mu Dan Pi (Tree Peony Bark) 15g, Rou Gui (Cinnamon Bark) 15g, ***12g, Niu Xi (Achyranthes Root) 15g, Che Qian Zi (Plantago Seed) 15g, Dang Gui (Chinese Angelica Root) 15g, **9g.

Therapeutic Effects:

1. Tonify kidney and replenish qi.
2. Strengthen the spleen and stomach.
3. Promote water metabolism and reduce swelling.
4. Activate blood circulation and alleviate stiffness.

Treatment Process: The patient reported significant improvement after one week of taking the modified Ji Sheng Kidney Qi Pill. After three weeks, the edema completely subsided, and the patient also noticed a considerable enhancement in energy levels. Although the tongue presentation still indicated insufficiency, the herbal formula was adjusted for another month as a consolidation treatment.

Follow-Up: The patient maintained a stable condition with no recurrence of symptoms. Tongue presentation gradually approached normal. The patient was advised to continue adopting a healthy lifestyle, engage in appropriate exercise, and maintain a balanced diet to prevent relapse.

Conclusion: This medical case illustrates the successful application of traditional Chinese medicine in the treatment of lower limb edema in a 72-year-old patient. The individualized herbal formula effectively addressed the underlying deficiency in kidney qi, resulting in a significant improvement in symptoms and overall well-being.

Case No. 096