叶金连,王洋,李灿东.李灿东教授辨治乳腺结节病1例[DB/OL].(2023-11-10)[2023-11-10].https://cccl-tcm.cacm.org.cn/thesisDetails?columnId=43820781&Fpath=home&index=0&lang=zh
[DB/OL].(2023-11-13)[2023-11-13].http://cccl-tcm.cacm.org.cn/thesisDetails?columnId=43820781&Fpath=home&index=0
病史摘要,2,患者张某,女,36岁,2021年12月21日初诊,主诉“体检发现右乳腺结节2个月”。现病史:患者于2021年10月26日至福建省立医院乳腺彩超示“右乳低回声结节,大小约2.8 mm×1.6 mm,BI-RADS 3类”,于2021年11月9日至福建省妇幼保健院复查乳腺钼靶示“右乳晕后区小结节,径约0.6 cm,BI-RADS 3类”。由于短期内乳腺结节增大,患者担忧,遂于2021年12月21日就诊李灿东教授门诊。李灿东教授辨本案为肝郁气滞,痰瘀互结,治以疏肝理气,健脾化痰,祛瘀散结,方选柴胡温胆汤加减治疗。患者药后胸闷、眠浅易醒、行经前乳房胀痛基本缓解,月经如常,彩超提示乳腺结节消失。四诊信息:时有胸闷,不欲食肉,眠浅易醒,经期后延,经色鲜红,经前伴有乳胀,舌暗红,苔黄腻,脉沉滑。中医诊断:乳癖,肝郁气滞,痰瘀互结证。中医治法:疏肝理气,健脾化痰,祛瘀散结。西医诊断:乳腺结节。干预措施:柴胡温胆汤加减。疗效转归:2022年7月8日复查,患者乳腺结节消失,中医症状基本消失。
Summary of case history ,Patient Zhang, female, 36 years old , first visited the clinic on December 21st, 2021, whose chief complain was that the right breast nodule was found in physical examination for 2 months. History of Present Illness: The patient went to Fujian Provincial Hospital on October 26th, 2021 for breast color ultrasound examination, which found the right breast hypoechoic nodule, size about 2.8 mm×1.6 mm , BI-RADS category 3. On November 9th, 2021, she went to Fujian Provincial Maternity and Children's Hospital for a reexamination, which showed small nodule in the posterior area of the right areola, about 0.6 cm in diameter, BI-RADS category 3. Due to the enlargement of the breast nodule in a short time, the patient was worried and visited Professor Li Candong's clinic on December 21st, 2021. Professor Li Candong identified the case as Liver-qi stagnation and phlegm-blood stasis, and treated it by soothing the liver and regulating qi, invigorating the spleen and eliminating phlegm, removing blood stasis and dispersing stagnation , and select Modified Chaihu Wendan Decoction as prescription. After taking the prescription, the patient's chest tightness, sleep disorder and premenstrual breast pain were basically relieved, and her menstruation was normal. Moreover, the color ultrasound showed that the breast nodules disappeared. Information Collected with the Four Diagnostic Methods: Chest tightness sometimes, no appetite for meat, light sleep and easy to wake, delayed menstruation, bright red menstrual blood color, accompanied by premenstrual breast swelling, dark red tongue, yellow and greasy tongue coating, deep and slippery pulse. TCM Diagnosis: Ru Pi, Syndrome of Liver-Qi Stagnation and phlegm-blood stasis. TCM Treatment: Soothing liver and regulating qi, invigorating the spleen and eliminating phlegm, removing blood stasis and dispersing stagnation. Western Medicine Diagnosis: Breast nodule. Interventions: Modified Chaihu Wendan Decoction. Curative Effect and Prognosis: The result of reexamination on July 8th, 2022 showed that the patient's breast nodule disappeared and her TCM symptoms basically disappeared.
乳腺结节柴胡温胆汤疏肝理气化痰祛瘀散结
breast nodulesChaihu Wendan Decoctionsoothing the liver and regulating qieliminating phlegm removing blood stasis and dispersing stagnation
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