中医病例讨论

1. 中医病例讨论 胃脘痛 （中焦阳虚）

2. 一.辩证导引 • Today we will discuss the TCM case of a 36-year-old man 。 • 今天我们要讨论的是3６岁男性中医病例.

3. 二.病史陈述 • First of all, I would like to present the case. 首先，我为大家介绍此病例

4. 二.病史陈述 • Today we will discuss the case of a 36-year-old man withrecurrent epigastric pain for five months. 今天我们要讨论的是一位近五个月以来上腹疼痛的36岁男性病例。

5. 二.病史陈述 • Five months ago,the patient felt epigastric pain.At that time,the amylase levels was 349 U per liter. The white-cell count and the results of tests of liver function were normal.the pain continued,and the amylase levels did not return to normal . • 五个月前,病人感到上腹疼痛.淀粉酶水平是349单位每升.白细胞数目和肝功能正常.疼痛继续.淀粉酶水平一直不正常.

6. 二.病史陈述 • Twelve weeks ago,he was administration of prednisone(20 mg twice daily). The patient’s pain resolved. The patient had lost 5.5 kg in weight during recent weeks. • 12周前,病人使用了强的松20毫克,每天两次.最近几周病人体重下降5.5公斤.

7. 二.病史陈述 • Sixteen weeks before admission，an endoscopic examination showed diffuse attenuation of the common bile duct and focal narrowing at the origin of the left hepatic duct • 入院前16周,内窥镜显示胆管变薄,左侧胆管变狭窄.

8. 二.病史陈述 • but the intrahepatic duct s were not optimally distended . The same day an upper gastrointestinal endoscopic examination showed abnormalities in the entire pancreas， • 但是肝内胆管无扩张.同一天的胃肠内窥镜显示胰腺的畸形.

9. 二.病史陈述 • He had a tendency toward constipation and urinary frequency.He had had no recent episodes of nausea,vomiting,or diarrhea.His paternal grandmother had died of “stomach cancer,”but there was no family history of pancreatitis. • 最近他有便秘和尿频现象.没有头晕恶心,呕吐,腹泻的现象.他的曾祖母死于胃癌,没有胰腺炎家族史.

10. 二.病史陈述 • Physical examination (体格检查) : • T 36.7 ℃ , HR83bpm,BP 115/75 mmHg;Normal development ,normal nourishment ,unpalpation of superficial lymph node,normal breath sound of the lung ,HR 83bpm ,regular. Slightly palpational pain in epigastric abdomen ,no palpational pain in other region ,without any reflect pain .No edema in the low extremities. • 发育正常，营养良好，浅表淋巴结未及，双肺呼吸音正常，心率83 bpm，律齐。中上腹轻压痛， 无反跳痛，其余部位无压痛，双下肢无水肿。

11. 二.病史陈述 • Inspection，Auscultation and Olfaction, pulse-feeling and palpation : • sallow complexion， fatigue looking , lassitude , reluctance to speak , emaciation , • cold limb aversion to cold ,eyeball without icterus. painful express. • 望、闻、切：面色萎黄,神疲乏力，少气懒言，形寒肢冷，恶寒，无黄睛，苦痛楚楚。

12. 二.病史陈述 • Inquiry : poor appetide ,constipation and urinary frequary , good sleep ,no nausea,vomiting,diarrhea. • 问诊：胃纳不馨，大便闭塞，小便清长，夜寐尚安。无恶心、呕吐、腹泻等症。 • Picture of the tongue : whitish enlarged tang with slight yellow fur in center . • 舌象：淡白胖大舌，中有薄黄苔 • Pulse -taking: Thin ,weak • 脉象：细 弱

13. 三.病证要点 • epigestric pain • 胃脘痛

14. 四.中医辨证 • Epigastric pain is a chronic persist ache in the upper abdomen. It can be caused by Qi asthemia ,pathogenic cold invasion and blood stasis，etc. • 胃脘痛是中上腹的慢性持续性疼痛，可以因为气虚、外寒入侵或是血瘀等引起。

15. 四.中医辨证 • It is not likely the dianosis of heart-ache. Because it usually companied with a series of cardiac sympotoms like irregular heart rate, short breath, palpitation , cardialgia .So heart disease is an unlikely disease in this case. • 鉴别诊断：真心痛：可有一系列心脏的症状伴随,如：心律失常、 短气、心悸、心痛等。本病程中无任何上述伴随症状出现，基本可以排除心脏病。

16. 五.病机分析 • It is because of insufficiency gastroplenic Yang .Asthenic Yang cause endogenous cold (said Nei Jing) ,coldness leads to ache .And the tongue and the pulse also suggest the diagnosis. • 本证主要因中焦阳气不足引起。《内经》云“阳虚则寒”，寒主痛，故中焦阳气不足而见胃脘痛。舌脉亦见阳气虚损症状。

17. 六.中医诊断 • Diagnosis of TCM: epigestric pain (insufficiency of gastrolenic Qi) • 入院中医诊断：胃脘痛（中焦阳虚）

18. 七.治疗原则 • Principle : invigorating Yang ，worming the stomach to liminate cold • 治则：温阳健脾，温中散寒

19. 八.方剂选择 • Prescription : Pegulating the Middle Decoction & Rour –Noble Drug Decoction • 方剂：理中汤（《伤寒论》）合四君子汤《圣济总录》