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一、病历介绍例一:黄××,女性,35岁,农民,1963年7月13日就诊.主诉:全身寒冷,手足冰凉一年多,每到夏天大热的天气,仍需要穿棉衣,脱去棉衣则感到寒冷难以忍受.食少乏味,身无力.使溏尿清.月经量少色淡.在当地治疗未效故来求治.察神志正常,面苍色黄,舌质状苔薄白,脉沉细而迟(氵啬),四肢冷至膝肘,身无汗而着厚衣(计棉衣1件,里、罩衣各一件).体温36℃,体检未发现异常.综上证属于脾肾两虚,阴寒内盛;脾阳不足,生化失司.肾阳不足,脾失温煦,脾气不升,故身寒,四肢厥冷,是为骨(疒卑).治以温补脾肾,益气散寒,方用附桂理中汤加减.药物用乌附片9克,白术9克,茯苓10克,干姜5克,桂枝9克,炙草9克,党参9克,白芍9克.以水浓煎200毫升,分2次服,每服100毫升,首诊给药2剂,服药后寒冷及四肢冷凉有明显改善,复诊时按原方加乌附片3克,给药3剂,服完后,解棉衣返家.
First, the introduction of medical records Example 1: Huang × ×, female, 35 years old, farmer, July 13, 1963. Chief complaint: cold, cold hands and feet more than a year, every hot summer weather, still need to wear cotton, Take off the cotton pad is feel unbearable cold. Eat less boring, weakness. 溏 urine clear. Menstrual less dull. In the local treatment is not effective to seek treatment. Cha mind normal, pale yellow, tongue-like coating thin White, veins thin and late (stingy), cold limbs knees to the elbow, body sweat-free and thick clothing (meter cotton one, in the gown each one.) Body temperature 36 ℃, physical examination found no abnormalities. Spleen deficiency, lack of spleen and Yang, lack of spleen-yang, loss of vital energy, lack of kidney yang, warm spleen, temper does not rise, so body cold, extremities Jueleng, is bone. Kidney, Qi and dispelling side with the addition and subtraction Guifu Li soup. Drugs Ukraine attached tablets 9 grams, Atractylodes 9 grams, Poria 10 grams, ginger 5 grams, 9 grams Cassia, 9 grams of Zhi Cao, Codonopsis 9 grams , White peony root 9 grams.Dried with 200 milliliters of water, divided into 2 times service, each serving 100 ml, the first visit to give medicine 2, cold and limbs after taking the medication has been significantly improved cold, referral when the original prescription plus Wu film 3 grams, 3 doses, after serving, solution cotton home.