医案四十七

患者姓名：陈某文     性别：男      年龄：42岁

就诊日期：2022-07-29               发病节气：大暑 

主诉：右胁肋部疼痛1月余。

现病史：1月前患者无明显诱因出现右胁肋部疼痛，查肝功能未见明显异常。现患者为求进一步诊治于门诊就诊，刻诊：右胁肋部疼痛，偶有疲倦乏力，咽喉部异物感，双手麻木，纳可，寐差，入睡难，大便溏结不调，1次/天，小便调。舌淡红，边有齿痕，苔白腻，脉弦。

既往史：：患者2022年08月于外院明确诊断“1、乙型肝炎小三阳；2、肝纤维化”，目前规律口服富马酸丙酚替诺福韦片抗病毒治疗（具体诊治经过不详）。有“丙型病毒性肝炎”“银屑病”病史（具体不详）。

过敏史：否认药物及食物过敏史。

体格检查：患者神志清楚，精神可，慢性肝病面容，表情自然。巩膜无黄染，无蜘蛛痣，无肝掌；心肺（-）；腹部无膨隆，无腹壁静脉曲张；腹部无压痛，肝脾肋下未触及，墨菲氏征（-）；肝上界位于右锁骨中线第5肋间，肝区叩击痛，移动性浊音（-）。

辅助检查：（2022-07 外院）乙肝两对半：乙肝表面抗原（+）、乙型肝炎病毒e抗体（+）；肝功能：总胆红素2.6μmol/L↓（3.4~17.1μmol/L）；间接胆红素1.8μmol/L（1.7-10.2μmol/L）；肝胆脾胰彩超：肝内光点增粗，请结合肝功能检查；胆囊多发小息肉。脾、胰超声未见异常。

中医诊断：胁痛

证候诊断：肝郁脾虚证

西医诊断：1.乙型肝炎小三阳；2.肝纤维化；3.丙型病毒性肝炎；4.银屑病

治法：疏肝健脾，活血止痛

处方：八珍荔核化纤方加减

当归10g      川芎10g      熟地黄10g     茯苓10g

麸炒白术10g  白芍10g      炙甘草6g      人参3g

荔枝核30g    烫水蛭3g     柴胡10g       黄芪15g      

丹参10g      山药10g      醋五味子6g    墨旱莲10g

海金沙10g    广金钱草10g  醋鸡内金10g   仙鹤草10g

烫水蛭3g     柴胡10g      茵陈10g       麸炒枳实10g

姜厚朴10g    鸡血藤10g    龙骨10g       牡蛎15g

炒栀子10g    牡丹皮10g    延胡索10g     炒川楝子6g

姜黄6g       木香6g       砂仁3g        桑枝15g                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               

30剂，水煎，日1剂，早晚分服

复诊：服药5月后复诊，右胁肋部疼痛已除，偶有疲倦乏力已除，咽喉部异物感已除，仍有双手麻木，纳可，寐一般，入睡难，二便调。舌淡红，边有齿痕，苔薄白，脉弦。（2022-11-19）乙肝两对半：表面抗原（+）、e抗体（+）、核心抗体（+）；肝功能：碱性磷酸酶39 U/L（男性45～125U/L,女性35～135U/L）；总胆固醇7.2 mmol/L（3.00~5.70mmol/L）；彩超：前列腺局部钙化灶。肝胆胰腺未见明显异常。乙肝病毒DNA、血常规未见明显异常。

【按语】本案患者右胁肋部疼痛，属于中医学“胁痛”范畴，缘由气机郁滞，肝脉失养，肝脾失调，脾失健运所致，故出现右胁肋部疼痛、双手麻木等肝脉失养之症，及疲倦乏力、大便溏结不调等脾失健运等症。舌淡红，边有齿痕，苔白腻，脉弦均为肝郁脾虚之象，故治以疏肝健脾，活血止痛，方选八珍荔核化纤方加减。方中八珍汤、黄芪益气补血，荔枝核行气散结，仙鹤草解毒补虚，水蛭破血逐瘀，姜黄破血行气，金钱草、茵陈利湿退黄，海金沙、炒栀子清热利湿，丹参、牡丹皮活血化瘀，山药补益脾肾，墨旱莲滋补肝肾，醋五味子益气生津，鸡内金健胃消食，麸炒枳实、姜厚朴、木香、砂仁行气消积，柴胡疏肝解郁，，鸡血藤活血补血，龙骨、牡蛎重镇安神，醋延胡索、炒川楝子活血止痛，桑枝祛风通络。二诊患者仍有双手麻木，故加桂枝10g后继续服用30付。