中医内科病证病案(例)摘要：第八例及其翻译

中医内科病证病案（例）摘要：
患者，女，68岁。

2019年7月12日初诊。

患者肢体关节重着、酸痛反复发作2年，每遇阴雨天病情加重。

2个月前因在寒冷环境中工作时间过长，出现肢体及双手近端指间关节重着、肿胀、酸痛加重，关节活动不利，晨起尤甚，晨僵可达2小时，肌肤麻木不仁。

舌质淡，苔白腻，脉濡缓。

根据上述摘要，在答题卡上完成书面分析。

1
中医疾病诊断：痹证（3分）
中医证候诊断：风寒湿痹-着痹（3分）
中医辨病辨证依据（含病因病机分析）：患者现以“肢体及双手近端指间关节重着、肿胀、酸痛加重，关节活动不利”为主症，可辨为痹证（1分）；根据其“关节重着，伴有晨僵，肌肤麻木不仁，舌质淡，苔白腻，脉濡缓”可辨证为风寒湿痹之着痹（1分）。

其是由湿邪兼夹风寒，留滞经脉，闭阻气血所致（2分）。

中医治法：除湿通络，祛风散寒（3分）
方药：薏苡仁汤加减（3分）
药物组成、剂量及煎服方法：（4分）薏苡仁12g 苍术9g 甘草6g 防风12g 麻黄12g 独活9g 当归9g 川芎9g 制首乌9g
羌活9g 桂枝9g
3剂，水煎服。

日一剂，早晚分服。

翻译:Summary of medical records (cases) of diseases and syndromes in internal medicine of traditional Chinese medicine;
Patient, female, 68 years old. First visit on July 12, 2019.
The patient's limb joints were heavy and sore for 2 years, and his condition worsened every rainy day. Two months ago, due to working in a cold environment for too long, the joints between the fingers of the limbs and hands were heavy, swollen and sore, and the joint activity was unfavorable, especially in the morning, and the morning stiffness could reach 2 hours, making the skin insensitive. The tongue is pale, the coating is white and greasy, and the pulse is slow.
According to the above summary, complete the written analysis on the answer sheet.
one
Diagnosis of diseases in traditional Chinese medicine: arthralgia syndrome (3 points)
Diagnosis of TCM syndrome: arthralgia due to wind-cold-dampness-arthralgia due to obstruction (3 points)
Syndrome differentiation basis of TCM (including etiology and pathogenesis analysis): The patient's main symptom is "heavy adhesion, swelling and soreness of the interphalangeal joints near the limbs and hands, and unfavorable joint movement", which can be distinguished as arthralgia syndrome (1 point); According to its "heavy joints, accompanied by morning stiffness, insensitive skin, pale tongue, white greasy fur and slow pulse", it can be differentiated as arthralgia due to wind-cold-dampness (1 point). It is caused by dampness combined with wind-cold, stagnation of meridians and blockage of qi and blood (2 points). Traditional Chinese medicine: removing dampness and dredging collaterals, expelling wind and dispelling cold (3 points)
Prescription: coix seed decoction (3 points)
Composition, dosage and decoction method: (4 points) Coicis Semen 12g Atractylodis Rhizoma 9g Glycyrrhizae 6g Saposhnikovia 12g Ephedra Radix Angelicae Pubescentis 9g Angelica 9g Chuanxiong 9g Radix Polygoni Multiflori 9g.
Notopterygium root 9g cassia twig 9g
3 doses, decocted in water. One dose a day, divided in the morning and evening.。