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李某某,男。65岁。退休工人。 1984年9月14日初诊。症见口唇溃烂,红肿,疼痛,伴流血,结痂。局部有灼热感,干燥。反复发作10年,加剧月余。每年秋季即发,经久不愈,饮食、说话均有妨碍,倍感痛苦。曾就诊于湖医附一院,确诊为“顽固性口唇渍疡”,并经病理切片,高度怀疑唇癌。建议回当地医院治疗。患者对治疗失去信心,一气之下将病历烧毁,在极痛苦的情况下而求治于中医。刻下伴畏寒发热,体温37.8℃,舌质淡,苔薄白,脉濡细。证属心脾积热,邪毒为患。治以清脾泻热,妆邪解毒。方用泻黄散合清胃散加减:柴胡15克
Li Mou, male. 65 years old. Retired workers. Newly diagnosed on September 14, 1984. Zheng Jian lips ulcers, redness, pain, accompanied by bleeding, crusting. Local burning sensation, dry. Repeated attacks for 10 years have exacerbated the rest of the month. Every autumn, it’s unrecoverable and it suffers from impaired diet and speech. He had been referred to the First Affiliated Hospital of Lake Medicine and was diagnosed with “obstinate oral and lip smears”. His pathological section was highly suspected of lip cancer. It is recommended to return to the local hospital for treatment. The patient loses confidence in the treatment, burns the medical record in an accident, and seeks treatment in Chinese medicine in extremely painful circumstances. Engraved with chills and fever, body temperature 37.8 °C, pale tongue, thin white fur, thin pulse. The card is a cardiopulmonary fever and cult poison. Governance to spleen and diarrhea heat, makeup, detoxification. Fang Xie Huang Sanhe Qingweisan addition and subtraction: Bupleurum 15g