“Medical Case” Wu Mou, male, 22 years old, student from Shanghai, hospital number 59.
Hospitalized with hepatitis on December 5, 1964. He had suffered from bone tuberculosis and intestinal tuberculosis. He had loose stools for a long time. Now he has pain and fatigue in both flanks. He can eat and sleep well. The treatment is to use Sini powder combined with Angelica Shaoyao powder and cinnamon sticks, which is intended to promote yang and qi, nourish blood and water, and pay three times. After taking the medicine, the pain in the hypochondrium was relieved. Because of the night sweats, I gave Huangqi Jianzhong Decoction to supplement the deficiency for three times.
December 13: Fever, aversion to cold, headache and sore throat, cough, chest tightness and hypochondral pain.
Three dollars of mulberry leaves, three dollars of chrysanthemum, two dollars of almonds, four dollars of reed roots, three dollars of forsythia, three dollars of bellflower, two dollars of mint Money, three money for light tempeh, two money for Qianghuo, and two money for roasted licorice. Second payment.
Exam: WBC: 8000, neutral: 70%, chest X-ray: right lung lower field atypical pneumonia (viral pneumonia).
December 14th: fever subsided after the medicine, spontaneous sweating, aversion to wind, cough, fullness of chest and hypochondriasis, antibiotics and infusion, until The high fever did not subside that night, the body temperature was 39°C, and the nose flaps, sweating on the head, and no fever in the body. It was a sign of heat stasis in the lungs. I gave Maxingganshi Decoction and Zhizizhi Decoction (prescription not recorded) . After taking 1/3 of the dose, at 11 o’clock in the night, the symptoms of numbness and cold limbs, palpitations and shortness of breath appeared.
December 15: Body temperature was 38°C, high fever in the afternoon, and body temperature was still above 39°C. There is cold and heat between exchanges, bitterness in the mouth and dry throat, dizziness, night sweats, no aversion to cold, and sweating profusely. The evidence is that the table has been resolved, the evil is spreading in Shaoyang, the heat is in Yangming, the table is sweating continuously, and the body fluid is seriously injured, and Xiaobuihu agent and raw gypsum are given.
Four bucks of Bupleurum, 3 bucks of Scutellaria, 3 bucks of Pinellia, 3 bucks of Codonopsis, 3 bucks of ginger, 3 jujubes, 3 pieces of licorice Two coins, two taels of raw gypsum. a pair of.
December 16: The person fell asleep in the second half of the night yesterday, but did not suffer from cold or heat, but was still dizzy, coughed, and vomited easily. Add raw oysters to the top. Second payment.
December 18: All symptoms disappeared and body temperature was normal.
December 19: Chest X-ray and lung lesions have been absorbed.
December 28: Discharge, outpatient treatment.
Analysis
This medical case is not easy to analyze, because it is a hospitalized patient who is taking traditional Chinese medicine while receiving infusion and other western medical treatment, so it is not easy to determine the specific cause when the curative effect or the aggravation of the disease is obtained. , and the situation on December 13th – “fever and aversion to cold, headache and sore throat, cough, chest tightness and hypochondral pain”, this belongs to Taiyang Shaoyang combined disease, you can consider the treatment of Chaihu Guizhi Decoction, at this time the choice is Sangju Drinking with added flavor is not like the style of Lao Hu, so this medical case will not be analyzed in detail.