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李博 男,中国中医科学院西苑医院 中医消化内科副主任医师,2006年毕业于北京中医药大学。 2005-2012曾担任丁香园循证医学版版主7年, 2014年获得NSFC国家自然科学基金青年项目资助 2015年入选北京市科技新星计划, 2015年入选中国中医科学院西苑医院育才计划。 2016年入选北京中医药传承“双百工程”唐旭东主任医师学术继承人 2016年1月出版小说体中西医消化内科科普书《胃靠养肠靠清》。

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美丽的莫西比利眼科医生TCM in Muhimbili for Sensitization dermatitis  

2009-09-28 04:02:58|  分类: 充实工作 |  标签: |举报 |字号 订阅

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美丽的莫西比利眼科医生TCM in Muhimbili for Sensitization dermatitis

 

Surname***

Other nameDr.MW***

Date of Birth1960  Sex:F

JobEye doctor in Muhimbili

Hospital Reg. Number:  A***

 

这是本院的眼科医生,是上次急诊科主任介绍来的新患者。

很高兴又有机会和当地的医生,进行一次交流。也许是视网膜效应,对眼科医师有特别的感情,我觉得这位眼科医师年纪不小了,但是她的眼睛依然很美丽,看不出来她已经是50岁的中年妇女,有气质而充满智慧。也许是因为眼科医师需要更多的凝神静气。

 

 

她的问题来自皮肤,这是她来我这里看病的过程。

 

 

初诊:2009917

主诉:手指及脖颈处皮肤脱屑反复发作7年余。

病史:患者从7年前开始出现皮疹,皮肤脱屑,位于手指及脖颈处,皮肤皱褶处明显,曾经过本院的皮肤科治疗。外用和口服激素类药物,效果不明显。皮肤的症状包括痒,脱屑,在切洋葱及土豆的时候加重,高领的衣服可刺激脖颈处的皮肤症状加重,有樟脑过敏症状,如果使用温度过低的水清洗,会加重痒的症状。纳食可,二便调,睡眠一般,偶有失眠,容易着急生气,平时喜温热。

 

查体:脖颈及手指白色脱屑,无肉芽组织。

实验室检查:未查

舌脉:舌体瘦小,舌淡红,苔白厚,脉位中,脉沉滑尺弱。

诊断:过敏性皮炎

辨证:风邪郁表,肝郁湿滞血瘀

治疗:疏肝活血祛风理气

处方:过敏煎和四物消风散加减

柴胡6   乌梅10  陈皮10  防风10

生地10  川芎10  当归10  赤芍10

苍术10  茯苓10  炙草6

六剂颗粒剂 冲服 每天一剂,每日两次

 

当归苦参丸2/1  Bid

湿毒膏3/外用  Qd

 

医嘱:远离过敏源,加强运动。

 

告知医疗博客:http:libo.haodf.com

 

 

Surname***

Other nameDr.MW***

Date of Birth1960  Sex:F

JobEye doctor in Muhimbili

Hospital Reg. Number:  A1**

Chief complaint: The breakout and desquamation recurrent attacks 7 years.

She complained that the breakout and desquamation recurrent comes 7 years agoThere are breakout and desquamation recurrents on the skins of the all fingers and neck. It were worse on the skinfolds. Patient feels itching. It was badly if touch the onion and potato or wear in the shirt with the high collar. It was worse in the morning and night. She was received Cortisone for the treatment. It was better for skin if use the hormonal therapy. It get worse itching if touch the cold water. She has the allergy with camphor. Her appetite, urine and stool were normal. She likes the warm food and water. She was easy to get angry on her live.

 

Physical examination: There are breakout and desquamation recurrents on the skins of the all fingers and neck.

Laboratory examination: None.

TCM examination: Tongue: The body of tongue was lanky. Red with white coating tongue.

Pulse: Huan and CHI RuoSlide and CHI-pulse being weak

Diagnosis: Sensitization dermatitis

TCM diagnosis: stagnation of liver-QI stagnation of blood

 

Therapy: disperse the depressed liver-energy; promoting blood flow; eliminating wind; regulating vital energy

Prescription:  Guomin Jian and Siwu Xiaofeng San

 

Name of herb in Chinese

Name of herb in English

Name of herb in Latin

Pronounce in TCM

Weightg

柴胡

Chinese Thorowax Root /Red Thorowax Root

Radix Bupleuri

Chaihu

6

乌梅

Dark Plum fruit

Fructus Mume

Wumei

10

陈皮

Tangerine Peel

Pericarpium Citri Reticulatae

Chenpi

10

防风

Divaricate Saposhnikovia Root

Radix Saposhnikoviae

Fangfeng

10

生地

Rehmannia Root

Radix Rehmanniae

Dihuang

10

川芎

Szechuan Lovage Rhizome

Rhizoma Chuanxiong

Chuanxiong

10

当归

Chinese Angelica

Radix Angelicae Sinensis

Danggui

10

赤芍

Red Paeony Root

Radix Paeoniae Rubra

Chishao

10

苍术

Swordlike Atractylodes Rhizome / Chinese Atractylodes Rhizome

Rhizoma Atractylodis

Cangzhu

10

茯苓

Indian Buead

Poria

Fuling

 

炙草

Liquoric Root

Radix Glycyrrhizae

Gancao

6

 

6

doses given. 1 dose per day taken orally twice a day.

Advice for the patient: Diet .Pay much attention to the food you take each time.

1 Take a king’s breakfast, having as many different kinds of food as you can; rich man’s lunch, having as much as you can; bagger’s dinner; that is taking as little as you can. The right time to have breakfast: 8:00a.m.; right time to have lunch: before  1:00p.m.; right time to have dinner: 7:00p.m.;

2It is better for you to take a light exercises..

3Go away from the things it can get the allergy.

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