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110 學年度中醫病案學期末報告
第 4 組、學號:B0505052、姓名:賴彥妤
基本資料
59 歲,女性,
主訴
虛弱倦怠、噁心嘔吐已三個月
現病史
於 108/9/5 體檢時發現肝功能指數異常(GOT223, GPT 205),因此於
9/15 至胃腸肝膽科門診進一步檢查,抽血檢驗 B 型及 C 型肝炎皆為陰
性反應,AFP 與總膽紅素皆在正常範圍。9/24 進行腹部超音波檢查,認
為有 gallstones and gallbladder distension with bilateral IHDs dilatation。
10/10 進行全腹部電腦斷層掃瞄,結果顯示 distended gallbladder with
stones and sludges and dilated IHD prefer from chronic cholangitis。10/14 胃
腸肝膽科回診時,醫師依據 CT 結果建議住院做 ERCP 及手術治療,原
本患者希望延後開刀,但當時醫師發現患者出現鞏膜黃疸,膽紅素升高(T-
Bil:4.78),隨即安排住院。
10/14 住院時進行 ERCP 發現為 hilar cancer。10/16 突發急性腹痛,
抽血發現 Amylase 1403, Lipase 1858.8。
10/20 進行手術:
1. Choledochotomy+ common bile duct biopsy+ T-tube + choledochoscopy;
2. Cholecystectomy。
手術後轉入 ICU 觀察,情況穩定於 10/21 轉出至外科病房,患者有
排氣並且進食情況穩定,於 10/27 移除 vaccumball#2,vacuum ball#1 及
t-tube 仍持續使用。10/27 病理切片結果確認為膽囊癌,adenocarcinoma,
well differentiated, T1N0 於 10/29 出院。
- 2 -
10/30(出院後第一天)虛弱倦怠至中醫求診。11/4 回診 GS OPD,開
始服用 Ufur cap (11/4, 11/11,11/18)。11/18 初次至腫瘤科門診,11/23 第
二次住院,作 bone scan:no evidence of bone metastasis。11/23 入院開始進
行第 1-5 次電療,11/24 手術置入 port-A ,11/25~11/28 開始第一次化療
(5FU/LV regimen),於 11/28 出院 12/2-12/27 完成第 6-25 次電療,12/28
移除 T-tube。108/12/29~109/1/1 患者再入院作第二次化療放化療後體力不
佳且噁心,持續於中醫部就診。
過去病史
過去有高血壓十多年以西藥控制。
104/3/22 車禍 Comminuted supra-intercondylar fracture of distal femur,
R't, open type I S/P ORIF(OpenReduction Internal Fixation)
個人史
素食 5-6 年 抽煙(-)
、喝酒(-)
、檳榔(-) G0P0, 50 歲停經。
家族史
父母親無特殊病史。弟弟罹患胰臟癌。
中醫四診
【望】
:形體瘦弱,面色萎黃
舌質淡,兩側光苔夾有瘀斑,舌前少苔,舌根苔厚,苔白夾黃苔
舌下絡脈無明顯怒張
【聞】
:無異常氣味
語音無力,短氣聲低
BS: clear, HS: no murmur
【問】
:疲倦無力
寒熱:怕冷,冬天手腳冰冷
汗:無明顯自汗或盜汗
睡眠:眠差,有壓力則難入眠,睡夢中易驚醒,夜尿 0-1 次
飲食:喜溫喜熱。開刀前食不適即會噁心欲吐,電化療後欲嘔加
重,食慾不振。食後常打嗝,無噯腐吞酸
二便:小便色黃,量適中,白日 2~3 小時一次,夜尿 0-1 次;大
- 3 -
便平常日一行,質無太軟或太硬,成形,色黃褐,但有時腹絞痛而泄瀉,便
糊,色黃褐
頭項:頭暈時發,無特殊規律及誘發因素;右顳側及太陽穴附近易
發偏頭痛,眠差甚,發作時自行按摩風池穴可減緩,無須服用止痛藥。
五官:口乾、咽乾,無口苦。食冰涼則覺氣管不舒,誘發咳嗽,咳
則誘發右上腹開刀處疼痛
四肢:夜間下肢易抽筋。手指麻感,活動按摩後較舒。右大腿無
力,右膝酸痛,氣候變化甚
胸腹:胸口有時覺悶。左胸 port-A 放置處及右上腹開刀處常覺膚
癢。有時繞臍絞痛腸鳴約 3-5 分鐘又自行緩解,有時痛後腹瀉,瀉後痛
減。中脘處疼痛感,飽食後甚。食後腹脹悶堵感,飽食甚。右脅肋悶脹感
腰背:腰痠,工作時穿護腰,工作後加重,工作時須搬重。
【切】
:脈沈澀弱、中脘處壓痛
理學檢查
L/E: no pitting edema
Murphy's sign: negative
實驗室檢查及特殊檢查
◆ 超音波檢查 108/9/24
Diagnosis:
Chronic parenchyma liver disease with fatty change.
Gallstones and GB distension with bilateral IHDs dilatation
◆ CT 108/10/10
IMP:
1. Distended gall-bladder with multiple stones and sludges.
2. Dilated IHD prefer from chronic cholangitis.
◆ 3D CT sim 108/11/18
Imp.
1. A case of GB cancer s/p operation and for R/T planning
2. S/PT-tube insertion with mild biliary tree dilatation.
3. Peritoneal carcinomatosis should be considered in this patient.
- 4 -
- 5 -
時序圖
病因病機圖
診斷
肝膽瘀阻,脾虛氣滯,氣血兩虛
- 6 -
鑑別診斷
1. 與肝膽濕熱證所造成的黃疸的鑑別:
肝膽濕熱證所造成的黃疸,症狀主要以身黃鮮明、發熱口渴、小
便短少黃赤、心中懊憹、舌苔黃膩、脈數等明顯熱象為主,與本
案中的喜溫、手腳冰冷等寒象有明顯區別,故知不宜以清熱利濕
法治之。
2. 與胃實熱或傷食所造成的噁心進行鑑別:
胃熱噁心會兼有胃脘灼痛、嘈雜、吞酸、口臭等本案未出現的症
狀;而傷食雖亦會有不欲飲食的症狀,但應會有噯腐吞酸之見
證,與本案不符,再加以本案有脅痛症狀,可推測此噁心感應為
肝鬱脾虛所造成的不適。
治法
疏肝利膽,健脾和胃,溫陽化濕,化瘀散結
處方
茵陳朮附湯+延胡索、鬱金、三稜、莪朮、遠志、砂仁
用藥
茵陳朮附湯:茵陳 3 克,白朮 6 克,附子 1.5 克,乾薑 1.5 克,甘草
(炙)3 克,肉桂(去皮)1 克
延胡索、鬱金各 2 克
三稜、莪朮、遠志、砂仁各 1.5 克
理法方藥分析
茵陳朮附湯方中茵陳為治黃疸之專藥,與溫中回陽之四逆湯並用,則
可溫化寒濕退黃;肉桂暖肝溫腎祛寒,白朮益氣溫中燥濕。諸藥合用,奏
溫中健脾、利濕退黃,以達到溫陽化濕的效果。
延胡索、鬱金皆有行氣止痛活血之效,助疏肝柔肝之餘,鬱金亦有利
膽退黃的療效,可助前述茵陳朮附湯的利膽之功。
三稜、莪朮皆可破血祛瘀、行氣止痛,其中莪朮為癌症的常用單味
藥,對積聚有良好療效。
遠志可寧心安神,可治本案的夜夢驚醒、驚悸失眠,也略有開竅祛痰
- 7 -
之效,協助化祛濕邪。
砂仁則可行氣化濕健脾,助運化濕阻以調養脾胃。
參考資料:
姚乃禮:
《中醫症狀鑑別診斷學》
程國彭:
《醫學心悟》
陳慧、尤建良:尤建良教授疏肝利膽消積方治療晚期膽囊癌術後經驗淺析

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中醫病案學期末報告.docx

  • 1. - 1 - 110 學年度中醫病案學期末報告 第 4 組、學號:B0505052、姓名:賴彥妤 基本資料 59 歲,女性, 主訴 虛弱倦怠、噁心嘔吐已三個月 現病史 於 108/9/5 體檢時發現肝功能指數異常(GOT223, GPT 205),因此於 9/15 至胃腸肝膽科門診進一步檢查,抽血檢驗 B 型及 C 型肝炎皆為陰 性反應,AFP 與總膽紅素皆在正常範圍。9/24 進行腹部超音波檢查,認 為有 gallstones and gallbladder distension with bilateral IHDs dilatation。 10/10 進行全腹部電腦斷層掃瞄,結果顯示 distended gallbladder with stones and sludges and dilated IHD prefer from chronic cholangitis。10/14 胃 腸肝膽科回診時,醫師依據 CT 結果建議住院做 ERCP 及手術治療,原 本患者希望延後開刀,但當時醫師發現患者出現鞏膜黃疸,膽紅素升高(T- Bil:4.78),隨即安排住院。 10/14 住院時進行 ERCP 發現為 hilar cancer。10/16 突發急性腹痛, 抽血發現 Amylase 1403, Lipase 1858.8。 10/20 進行手術: 1. Choledochotomy+ common bile duct biopsy+ T-tube + choledochoscopy; 2. Cholecystectomy。 手術後轉入 ICU 觀察,情況穩定於 10/21 轉出至外科病房,患者有 排氣並且進食情況穩定,於 10/27 移除 vaccumball#2,vacuum ball#1 及 t-tube 仍持續使用。10/27 病理切片結果確認為膽囊癌,adenocarcinoma, well differentiated, T1N0 於 10/29 出院。
  • 2. - 2 - 10/30(出院後第一天)虛弱倦怠至中醫求診。11/4 回診 GS OPD,開 始服用 Ufur cap (11/4, 11/11,11/18)。11/18 初次至腫瘤科門診,11/23 第 二次住院,作 bone scan:no evidence of bone metastasis。11/23 入院開始進 行第 1-5 次電療,11/24 手術置入 port-A ,11/25~11/28 開始第一次化療 (5FU/LV regimen),於 11/28 出院 12/2-12/27 完成第 6-25 次電療,12/28 移除 T-tube。108/12/29~109/1/1 患者再入院作第二次化療放化療後體力不 佳且噁心,持續於中醫部就診。 過去病史 過去有高血壓十多年以西藥控制。 104/3/22 車禍 Comminuted supra-intercondylar fracture of distal femur, R't, open type I S/P ORIF(OpenReduction Internal Fixation) 個人史 素食 5-6 年 抽煙(-) 、喝酒(-) 、檳榔(-) G0P0, 50 歲停經。 家族史 父母親無特殊病史。弟弟罹患胰臟癌。 中醫四診 【望】 :形體瘦弱,面色萎黃 舌質淡,兩側光苔夾有瘀斑,舌前少苔,舌根苔厚,苔白夾黃苔 舌下絡脈無明顯怒張 【聞】 :無異常氣味 語音無力,短氣聲低 BS: clear, HS: no murmur 【問】 :疲倦無力 寒熱:怕冷,冬天手腳冰冷 汗:無明顯自汗或盜汗 睡眠:眠差,有壓力則難入眠,睡夢中易驚醒,夜尿 0-1 次 飲食:喜溫喜熱。開刀前食不適即會噁心欲吐,電化療後欲嘔加 重,食慾不振。食後常打嗝,無噯腐吞酸 二便:小便色黃,量適中,白日 2~3 小時一次,夜尿 0-1 次;大
  • 3. - 3 - 便平常日一行,質無太軟或太硬,成形,色黃褐,但有時腹絞痛而泄瀉,便 糊,色黃褐 頭項:頭暈時發,無特殊規律及誘發因素;右顳側及太陽穴附近易 發偏頭痛,眠差甚,發作時自行按摩風池穴可減緩,無須服用止痛藥。 五官:口乾、咽乾,無口苦。食冰涼則覺氣管不舒,誘發咳嗽,咳 則誘發右上腹開刀處疼痛 四肢:夜間下肢易抽筋。手指麻感,活動按摩後較舒。右大腿無 力,右膝酸痛,氣候變化甚 胸腹:胸口有時覺悶。左胸 port-A 放置處及右上腹開刀處常覺膚 癢。有時繞臍絞痛腸鳴約 3-5 分鐘又自行緩解,有時痛後腹瀉,瀉後痛 減。中脘處疼痛感,飽食後甚。食後腹脹悶堵感,飽食甚。右脅肋悶脹感 腰背:腰痠,工作時穿護腰,工作後加重,工作時須搬重。 【切】 :脈沈澀弱、中脘處壓痛 理學檢查 L/E: no pitting edema Murphy's sign: negative 實驗室檢查及特殊檢查 ◆ 超音波檢查 108/9/24 Diagnosis: Chronic parenchyma liver disease with fatty change. Gallstones and GB distension with bilateral IHDs dilatation ◆ CT 108/10/10 IMP: 1. Distended gall-bladder with multiple stones and sludges. 2. Dilated IHD prefer from chronic cholangitis. ◆ 3D CT sim 108/11/18 Imp. 1. A case of GB cancer s/p operation and for R/T planning 2. S/PT-tube insertion with mild biliary tree dilatation. 3. Peritoneal carcinomatosis should be considered in this patient.
  • 6. - 6 - 鑑別診斷 1. 與肝膽濕熱證所造成的黃疸的鑑別: 肝膽濕熱證所造成的黃疸,症狀主要以身黃鮮明、發熱口渴、小 便短少黃赤、心中懊憹、舌苔黃膩、脈數等明顯熱象為主,與本 案中的喜溫、手腳冰冷等寒象有明顯區別,故知不宜以清熱利濕 法治之。 2. 與胃實熱或傷食所造成的噁心進行鑑別: 胃熱噁心會兼有胃脘灼痛、嘈雜、吞酸、口臭等本案未出現的症 狀;而傷食雖亦會有不欲飲食的症狀,但應會有噯腐吞酸之見 證,與本案不符,再加以本案有脅痛症狀,可推測此噁心感應為 肝鬱脾虛所造成的不適。 治法 疏肝利膽,健脾和胃,溫陽化濕,化瘀散結 處方 茵陳朮附湯+延胡索、鬱金、三稜、莪朮、遠志、砂仁 用藥 茵陳朮附湯:茵陳 3 克,白朮 6 克,附子 1.5 克,乾薑 1.5 克,甘草 (炙)3 克,肉桂(去皮)1 克 延胡索、鬱金各 2 克 三稜、莪朮、遠志、砂仁各 1.5 克 理法方藥分析 茵陳朮附湯方中茵陳為治黃疸之專藥,與溫中回陽之四逆湯並用,則 可溫化寒濕退黃;肉桂暖肝溫腎祛寒,白朮益氣溫中燥濕。諸藥合用,奏 溫中健脾、利濕退黃,以達到溫陽化濕的效果。 延胡索、鬱金皆有行氣止痛活血之效,助疏肝柔肝之餘,鬱金亦有利 膽退黃的療效,可助前述茵陳朮附湯的利膽之功。 三稜、莪朮皆可破血祛瘀、行氣止痛,其中莪朮為癌症的常用單味 藥,對積聚有良好療效。 遠志可寧心安神,可治本案的夜夢驚醒、驚悸失眠,也略有開竅祛痰