患者羡某,男,24岁,自述午睡后头顶痛麻木,口干渴,喜喝热饮,乏力,胸闷心悸睡醒后加重。患有颈椎病5年,入伍前血压150/90。现症见:困倦嗜睡,腹部怕冷,腰酸疼脚凉,夜晚鼻塞,头昏沉精力下降,颈肩沉重僵硬疼痛怕凉,头发木,脸怕风,偶尔突现头昏、心悸,大便干,小便可。舌质淡,苔白腻,有齿痕,舌中根部裂纹。
一诊11.1予以桂附地黄丸加减5付
口渴、胸闷乏力心悸缓解,腹部怕冷、头昏沉、精力差、腰酸疼消失,大便一日一次,成形不干,便畅,微黏。但夜晚鼻塞、颈肩沉重僵硬疼痛怕冷,头发木,脸怕风无缓解。舌质淡,白腻苔消失,根部裂纹消失,中部裂纹稍有愈合,齿痕变小。
二诊11.9予以自拟方颈通汤5付
期间受寒,鼻塞加重,未发烧,嘱其等感冒痊愈后在服,3日后,观其舌象无变化,嘱其继服,至昨日鼻塞、颈肩僵硬沉重,脖子凉,脸怕风缓解。
![](http://tiebapic.baidu.com/forum/w%3D580/sign=43fe078c9758ccbf1bbcb53229d8bcd4/4572d109b3de9c82217857b12a81800a19d8439e.jpg?tbpicau=2024-09-02-05_55dcf6080f26959d67a64142e7465277)
![](http://tiebapic.baidu.com/forum/w%3D580/sign=da09b6fba6fe9925cb0c695804a85ee4/43c4f01f3a292df500de022bfa315c6034a8739e.jpg?tbpicau=2024-09-02-05_d041e8a6754b0415d851658a02a2fc43)
![](http://tiebapic.baidu.com/forum/w%3D580/sign=2233d25a4f23dd542173a760e109b3df/89f58db1cb134954e003465a104e9258d1094a9e.jpg?tbpicau=2024-09-02-05_14df40291c10ee60f03ca17aad929434)
![](http://tiebapic.baidu.com/forum/w%3D580/sign=5d3e33ddbb1f4134e0370576151f95c1/e4d0828ba61ea8d3063fda3ad10a304e251f589e.jpg?tbpicau=2024-09-02-05_539b55ed8f0480c05152c393ac4a3c9a)
![](http://tiebapic.baidu.com/forum/w%3D580/sign=243e0ec497c8a786be2a4a065709c9c7/4020304e251f95cad0e93c888f177f3e6709529e.jpg?tbpicau=2024-09-02-05_da70a626f1109c4f8058fd97d558a309)
一诊11.1予以桂附地黄丸加减5付
口渴、胸闷乏力心悸缓解,腹部怕冷、头昏沉、精力差、腰酸疼消失,大便一日一次,成形不干,便畅,微黏。但夜晚鼻塞、颈肩沉重僵硬疼痛怕冷,头发木,脸怕风无缓解。舌质淡,白腻苔消失,根部裂纹消失,中部裂纹稍有愈合,齿痕变小。
二诊11.9予以自拟方颈通汤5付
期间受寒,鼻塞加重,未发烧,嘱其等感冒痊愈后在服,3日后,观其舌象无变化,嘱其继服,至昨日鼻塞、颈肩僵硬沉重,脖子凉,脸怕风缓解。
![](http://tiebapic.baidu.com/forum/w%3D580/sign=43fe078c9758ccbf1bbcb53229d8bcd4/4572d109b3de9c82217857b12a81800a19d8439e.jpg?tbpicau=2024-09-02-05_55dcf6080f26959d67a64142e7465277)
![](http://tiebapic.baidu.com/forum/w%3D580/sign=da09b6fba6fe9925cb0c695804a85ee4/43c4f01f3a292df500de022bfa315c6034a8739e.jpg?tbpicau=2024-09-02-05_d041e8a6754b0415d851658a02a2fc43)
![](http://tiebapic.baidu.com/forum/w%3D580/sign=2233d25a4f23dd542173a760e109b3df/89f58db1cb134954e003465a104e9258d1094a9e.jpg?tbpicau=2024-09-02-05_14df40291c10ee60f03ca17aad929434)
![](http://tiebapic.baidu.com/forum/w%3D580/sign=5d3e33ddbb1f4134e0370576151f95c1/e4d0828ba61ea8d3063fda3ad10a304e251f589e.jpg?tbpicau=2024-09-02-05_539b55ed8f0480c05152c393ac4a3c9a)
![](http://tiebapic.baidu.com/forum/w%3D580/sign=243e0ec497c8a786be2a4a065709c9c7/4020304e251f95cad0e93c888f177f3e6709529e.jpg?tbpicau=2024-09-02-05_da70a626f1109c4f8058fd97d558a309)