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例1:患者刘××,男,30岁,病历号99641。主诉:下唇经常发生裂沟,肿胀,出血,感觉疼痛,约有3年之久,病史过去曾吹过啦以和号。临床所见:体格营养中等,体查无异常发现,下唇唇红中部有2个并行纵裂沟,底面较深,创面呈红色,触易出血和疼痛,整个唇轻度肿胀,颌下无肿大淋巴结。印象:慢性唇炎(裂沟型) 治疗经过:用中西医结合治疗,经过2个月时间,痊愈,裂沟逐渐缩小,肿胀相继消退,最后裂沟完全愈合。局部治疗使用0.5％雷夫奴尔溶液湿敷。全身治疗:服用中药,处方:防风,荆芥,黄芩,石膏,山槴,薄荷,赤芍,连翘,鲜生地各3g,甘草1.5g,
Example 1: Patient Liu × ×, male, 30 years old, medical record number 99641. Chief Complaint: The lower lip often cracks, swelling, bleeding, feeling pain, about 3 years, the history of the past had been blown to the and number. Clinical findings: physical fitness medium, no abnormalities found in the body, the lower lip red central 2 longitudinal fissure groove, deep bottom, the wound was red, bleeding and painful touch, mild swelling of the entire lip, submandibular Swollen lymph nodes. Impression: Chronic cheilitis (fissure type) after treatment: Integrative Medicine, after 2 months time, healed, fissures dwindling, swelling have subsided, the final cleft completely healed. Topical treatment using 0.5% Reif Nuo solution wet compress. Whole body treatment: taking traditional Chinese medicine, prescription: wind, Nepeta, skullcap, gypsum, mountain shrews, mint, red peony root, forsythia,