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杭州市名中医吴滇医案三则-
杭州市名中医吴滇医案三则

杭州市名中医吴滇医案三则

吴滇主任中医师是杭州市名中医,从医四十余载,经验颇丰,就诊者众多。笔者有幸为吴老侍诊抄方学习,受益匪浅。现记录吴老医案三则,介绍学习心得如下。

1.淋证

陈某,女性,45岁。就诊时诉尿意频频,淋沥不尽,尿道涩痛,小腹拘急反复发作已5年,发作时去门诊口服或者静脉应用抗生素后症状缓解,但是每遇疲劳或者其他原因即易复发,近年常伴腰酸乏力,疲惫不堪。此次就诊查小便白细胞,红细胞及蛋白阴性,洁尿培养阴性。患者面色无华,胃纳减少,平素大便溏薄,舌红、苔薄黄腻,脉滑细。病为淋证。证属膀胱湿热,脾肾不足。处方:萹蓄、瞿麦、石韦、丹皮、生地、山药、泽泻、甘草、车前子、茯苓各10g,大叶金钱草、萸肉、米仁、白茅根各30g。每日1剂,水煎温服。7剂。

二诊:患者尿频急涩痛明显好转,仍感腰酸乏力,大便溏薄,舌红、苔薄,脉细。尿常规复查正常。处方:萸肉、大叶金钱草、米仁各30g,生地、泽泻、丹皮、茯苓、山药、黄芪、白术、女贞子、补骨脂、台乌药、益智仁、杜仲、狗脊、车前子各10g。14剂。药后患者自觉腰酸等症基本缓解。患者继续门诊巩固治疗达半年之久。随访2年,未再复发。

按:吴老认为患者反复发作尿频尿急已多年,证属本虚标实,其病理改变是肾虚膀胱热,脾肾亏虚为其本,膀胱湿热为其标。本虚是导致其反复发作的主要原因,但初诊时下焦湿热比较突出,此时治疗当急则治其标,清化膀胱湿热为主,兼顾脾肾。二诊时湿热之邪基本已除,缓则治其本,以补益脾肾为主,适当佐以清利下焦湿热之品,故以六味地黄丸合缩泉丸化裁。吴老认为淋证急性期治疗并不困难,困难的是如何预防复发,其关键在于巩固阶段疗程宜长,并常加入黄芪、补骨脂等,以补益脾肾,扶正祛邪。同时要注意适当休息,养成良好的卫生习惯。

2.胁痛

吴某,男性,41岁。发现慢性乙型肝炎30余年,3年前开始反复出现肝功能异常,蛋白比例倒置,平素自觉右侧胁肋部隐痛不适,疲劳后加重,伴有口干舌燥,烦热头晕。就诊时面色灰黯,舌黯紫、苔少,脉弦细。病为胁痛。证属肝阴不足,兼有血瘀。处方:生地、麦冬、沙参、鳖甲、当归、川芎、五味子、桃仁、赤芍、白芍、甘草各10g,马鞭草、垂盆草、茵陈各30g,红花3g。每日1剂,水煎温服。14剂。

二诊:患者胁痛明显减轻,复查肝功能正常,但时有乏力倦怠,便溏,纳可,舌淡紫、苔薄,脉弦细。处方:生地、麦冬、沙参、鳖甲、当归、川芎、丹参、猪苓、茯苓、白术、黄芪、女贞子、黄精各10g,马鞭草、米仁各30g。14剂后症状明显减轻。上方加减服用半年,症状消失,恢复上班,肝功能蛋白比例复查正常。追踪达两年之久,目前生化指标均正常。

按:吴老认为患者宿有肝疾,日久耗阴伤血,精血不旺,阴血难以濡养肝脉,病久入血入络,兼有血瘀。治疗当养阴柔肝,兼以活血通络。肝阴虚则脉绌急,肝之脉贯膈布胁肋,阴血燥则经脉失养而痛。肝病日久易克脾犯胃,脾胃又为后天之本,气血化生之源,故吴老强调护肝之时不忘健脾。

3.胃痛

朱某,女性,52岁。反复上腹部隐痛、泛酸2年,胃镜诊断为胃窦及十二指肠复合性溃疡。就诊时上腹部疼痛,饥饿时明显,伴有嘈杂痞满,泛酸,舌淡、苔白腻,脉细。病为胃痛。证属中焦气滞湿阻。处方:蒲公英、黄芩、蛇舌草、川朴、木香、枳壳、槟榔、当归、丹参、九香虫、苏木各10g,米仁30g,黄连、吴萸各5g。每日1剂,水煎温服。10剂。

二诊:自觉症状基本消失,平素患者喜温畏寒,体倦乏力,食欲不振,大便溏薄,舌淡、苔白。处方:党参、白术、茯苓、炙甘草、黄芪、当归、丹参、桂枝、木香各10g,干姜3g,煨葛根、米仁、红枣各30g。上方加减服用50剂。复查胃镜溃疡愈合。随访两年,未再复发。

按:吴老认为患者本虚标实,脾胃素虚,气机不畅,水湿不运,郁滞化热。治宜清化湿热,调理气机。10天后脾湿已化,气机转畅,当益气健脾以扶正,标本兼顾,陈疴得愈。

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