“Medical Record” Pu Mou, male, 34 years old, medical record number 030093.
First visit on March 9, 1964: Su suffers from chronic hepatitis, the back pain has almost healed, and the stool is very dry , so hemorrhoids flare up again, anal pain, taking western medicine to relieve the pain, blood in the stool, dull pain in the liver area, unable to sleep on the right side for three or four months at night, good appetite, yellow urine, dreamy sleep, tongue coating White thin and greasy, thin pulse.
Four bucks of Bupleurum, 4 bucks of Paeonia lactiflora, 3 bucks of Pinellia, 3 bucks of Scutellaria baicalensis, 3 bucks of Citrus aurantium Money, 3 money for peach kernels, 3 money for Danpi, 2 money for winter melon seeds, 2 money for rhubarb, 2 money for Glauber’s salt (Fenhong), 3 money for ginger, 4 jujubes, 2 money for licorice. Three payments.
Follow-up on March 12: After taking the medicine, the stools were excreted like blisters and fat sea-like sticky substances, the hypochondral pain was relieved, The pain of hemorrhoids has disappeared, and then go to the top of the mirabilite to inform it, and pay three times.
Analysis< /span>
“The liver area is dull and painful, and I can’t sleep on the right side at night” This refers to pain in the right flank, “anal pain” Pain, blood in the stool” This is caused by severe dry stools.
1. At first glance, the flank pain and dry stools seem to be Shaoyang-Yangming disease. Consider choosing Dachai Hu decoction treatment;
2, but the sick family has white and greasy fur, thin and stringy pulse, and there is no yangming on the whole. It is more appropriate to consider Xiao Chai Hu Tang;
3, and sleep more than a dream, so use firewood Hujia Dragon Bone Oyster Soup is more suitable;
4. Severe dry stool, you can add Glauber’s salt;
5. Pain in the right flank but unable to sleep on the right side, indicating that the deficiency and stasis are blocked, so choose Shaoyao Gancao Decoction.
In general, consider using Chaihu Jialonggu Muli Decoction and Shaoyao Gancao Decoction and Glauber’s Salt.
He chose Dachaihu Decoction, Dahuang Mudan Decoction and Shaoyao Gancao Decoction. The evidence is not obvious, and there is no obvious pus or blood stasis. The reason for Hu Lao’s choice is unknown.
Symptoms resolved at follow-up visit, and subsequent outcomes are unknown.