中医病例分析.docxVIP

中医病例分析

目录

一、病历概览................................................2

1.1病例来源.............................................2

1.2患者基本信息.........................................3

1.3主诉与现病史.........................................3

1.4既往史...............................................4

1.5家族史...............................................5

1.6个人史...............................................6

1.7体格检查.............................................7

二、辅助检查................................................8

2.1实验室检查...........................................8

2.2影像学检查...........................................9

2.3肺功能检测..........................................11

2.4心电图检查..........................................12

三、中医诊断...............................................13

3.1辨证论治............................................13

3.2中医辨证分型........................................15

3.3治疗原则............................................16

四、治疗方案...............................................17

4.1中药治疗............................................18

4.2针灸治疗............................................19

4.3推拿按摩............................................20

4.4食疗建议............................................22

五、治疗效果评估...........................................23

5.1症状改善情况........................................24

5.2体质改善情况........................................25

5.3生活质量提高情况....................................26

六、病例讨论...............................................27

6.1讨论要点............................................28

6.2病例的典型性........................................29

6.3体会与启示..........................................30

七、总结与展望.............................................31

7.1治疗效果总结........................................32

7.2未来研究方向........................................33

一、病历概览

男，45岁，主诉：腰痛。患者自述腰痛已有数月之久，起初为间歇性疼痛，后逐渐加重，且伴有下肢麻木、无力等症状。患者平时工作繁忙，长时间站立或坐着，饮食不规律，睡眠质量差。近期因劳累而加重病情，患者无明显发热、尿频、尿痛等症状，无外伤史。家族中无类似病史。

体格检查：患者