📄 病历记录 1 / Case Record 1

就诊日期 / Date of Visit： 2025年10月14日

性别 / Gender： 男 / Male

职业 / Occupation： 装修检测员 / Building Inspection Technician

一、主诉 / Chief Complaint

小结节复查。

Follow-up examination of pulmonary nodules.

二、现病史 / History of Presenting Illness

患者于2018–2019年体检时查出肺部小结节，之后两年复查（2023年）情况稳定。2025年9月复查发现小结节较前缩小约1/5–2/5。近期出现肺炎，已口服抗生素约10天，疑仍有炎症。复查CT显示炎症部分吸收。患者自诉无明显呼吸道症状。

生活习惯： 从不吸烟，偶尔饮啤酒。

The patient was found to have small pulmonary nodules during a routine health check in 2018–2019. Follow-up examinations over the next two years (up to 2023) showed stable findings. In September 2025, a repeat CT scan revealed that the nodules had reduced in size by approximately 1/5 to 2/5 compared to previous scans. Recently, the patient developed pneumonia and has been on oral antibiotics for about 10 days; residual inflammation is still suspected. A follow-up CT scan shows partial resolution of the inflammatory changes. The patient reports no significant respiratory symptoms.

Lifestyle： Non-smoker; occasionally drinks beer.

三、舌诊 / Tongue Diagnosis

舌红、有裂纹、齿痕。

提示：阴虚夹湿。

Red tongue with cracks and teeth marks.

Indicates：Yin deficiency with concurrent dampness.

四、西医诊断 / Western Medical Diagnosis

静默性肺炎（Silent Pneumonia）。

五、中医辨证分析 / TCM Pattern Differentiation

患者肺部小结节既往存在，近期因感染而复发炎症。舌红、裂纹为阴虚内热之象，舌边齿痕提示脾虚湿滞。既有阴虚，又夹痰湿与肺热，属阴虚肺热、痰湿蕴肺之证。

The patient has a history of pulmonary nodules, with recent inflammation triggered by infection. The red tongue with cracks indicates internal heat due to Yin deficiency, while teeth marks on the tongue margin suggest Spleen deficiency with dampness retention. This presents as a combination of Yin deficiency, phlegm-dampness, and lung heat — fitting the pattern of Lung Heat with Yin Deficiency and Phlegm-Dampness Accumulation in the Lung.

六、治法 / Treatment Principle

清宣肺气、化痰止咳、润肺养阴。

Clear and diffuse Lung Qi, transform phlegm and stop cough, moisten the Lung and nourish Yin.

七、方药处方 / Prescription

桑杏方（桑叶、杏仁、沙参、贝母、浙贝、梨皮、栀子）+ 二陈汤（陈皮、法夏、茯苓、甘草）变方

方义简析 / Formula Analysis

方中以桑叶、桑白皮、枇杷叶、紫苑清肺润燥、化痰止咳；杏仁、桔梗宣降肺气；陈皮、半夏理气化痰；甘草调和诸药。整体以清宣化痰、润肺止咳为主，兼顾气机宣畅与阴分滋润。

In this formula, Sangye (Mulberry Leaf), Sangbaipi (White Mulberry Root-bark), Pipaye (Loquat Leaf), and Ziyuan (Tatarinan Aster) clear the Lung, moisten dryness, transform phlegm, and stop cough. Xingren (Bitter Apricot Seed) and Jiegeng (Platycodon) regulate the ascending and descending of Lung Qi. Chenpi (Tangerine Peel) and Banxia (Pinellia) regulate qi and transform phlegm. Gancao (Licorice) harmonizes all the ingredients. The overall effect is to clear, diffuse, transform phlegm, moisten the Lung, and stop cough, while also ensuring the smooth flow of qi and nourishment of Yin.

八、建议 / Recommendations

保持良好作息，避免熬夜与辛辣油腻食物。
可配合中药调理1–2周后复查症状与舌象变化。
若炎症未完全吸收，可考虑加用养阴清热或软坚散结之品（如浙贝母、沙参、麦冬等），以防复发。
Maintain a regular sleep schedule; avoid staying up late, spicy foods, and greasy foods.
Follow up with TCM herbal therapy for 1–2 weeks, then reassess symptoms and tongue presentation.
If inflammation does not fully resolve, consider adding herbs that nourish Yin, clear heat, or soften and dissolve nodules (e.g., Zhebeimu, Shashen, Maidong) to prevent recurrence.