【摘要】：目的:導師袁海波教授近五十年來從事中醫(yī)藥研究以及診療工作,善于運用中醫(yī)藥理論防治內(nèi)科心血管疾病及相關臟腑疾患,在繼承和發(fā)揚前人治療心血管疾病經(jīng)驗的基礎上,結(jié)合自身治療本病的臨證經(jīng)驗,創(chuàng)立保元養(yǎng)心方,臨證應用時靈活加減變化,取得了顯著的臨床療效。本課題通過跟師隨診、與師交流、收集和整理總結(jié)醫(yī)案,總結(jié)了導師對胸痹心痛病的理論認識,創(chuàng)立保元養(yǎng)心方的基本背景及理論基礎,探索保元養(yǎng)心方的組成、方義及臨證應用的加減用藥。通過對醫(yī)案的研究,總結(jié)了常見的癥狀、舌象、脈象、兼證、用藥頻次、藥物功能分類等,為中醫(yī)的經(jīng)驗傳承,和中醫(yī)藥的繼承發(fā)展提供助力。方法:一、學術(shù)思想研究1.充分利用網(wǎng)絡資源及報紙刊物,在中國知網(wǎng)、萬方數(shù)據(jù)庫,翻閱查詢中醫(yī)藥雜志、中醫(yī)研究等刊物,收集詳讀導師著作文章及著作等,反復閱讀、研究思考、標注重點,不懂之處請教導師,體會導師診病經(jīng)驗,初步總結(jié)導師對胸痹心痛病的總體認識及保元養(yǎng)心方創(chuàng)立的基本背景、思路。2.跟師期間,侍其左右抄方隨診,隨時記錄筆記,包括導師用藥的經(jīng)驗及談醫(yī)話,時常翻閱回憶,對重點難點標注后請教導師,及時與導師進行學術(shù)探討與溝通,精心記錄學習內(nèi)容,并進一步進行修改、補充、完善。二、病案研究1.收集2015年4月至2015年12月期間導師運用保元養(yǎng)心方治療的胸痹心痛的,理、法、方、藥完善的醫(yī)案76例。2.在導師指導下,依據(jù)第七版中醫(yī)內(nèi)科學(中醫(yī)類專業(yè)用,周仲英主編)對胸痹心痛病進行診斷,依據(jù)第五版中藥學教材對醫(yī)案中出現(xiàn)的藥物進行分類,教材中未出現(xiàn)的中藥材依據(jù)《中藥大辭典》(第二版,南京中醫(yī)藥大學編著)進行統(tǒng)一規(guī)范。3.依據(jù)第七版中醫(yī)診斷學(中醫(yī)類專業(yè)用,朱文鋒主編),參考“十一五”國家科技支撐計劃課題,袁海波教授學術(shù)思想及臨證經(jīng)驗醫(yī)案觀察表,將原始醫(yī)案術(shù)語規(guī)范化,把原始醫(yī)案轉(zhuǎn)化為規(guī)范醫(yī)案。4.建立Excel醫(yī)案數(shù)據(jù)庫,將收集到的醫(yī)案按患者編號、性別、年齡、癥狀、舌象、脈象、證型、治法、方藥完整地錄入,反復核對數(shù)據(jù)庫信息確保信息的準確性。5.運用SPSS19.0軟件,對Excel醫(yī)案數(shù)據(jù)庫的數(shù)據(jù)采用頻數(shù)統(tǒng)計分析,統(tǒng)計應用了保元養(yǎng)心方診療的胸痹心痛病患者的性別、年齡、癥狀、舌象、脈象、證型、治法、方藥等分布情況。同時進行保元養(yǎng)心方藥物加減組成的分析。結(jié)果:一、學術(shù)思想研究結(jié)果1.導師認為,胸痹心痛病應獨立命名,其病位在心,相似于現(xiàn)代醫(yī)學中的冠心病心絞痛,臨證中注重輕癥與重癥的區(qū)分,導師認為胸痹心痛病的病因主要有四個方面:寒濕侵襲、損陽傷正;飲食不節(jié)、痰濕內(nèi)生;七情內(nèi)傷、氣血瘀滯;勞逸無度、傷心損脾。證分四型:氣陰兩虛型;痰濕阻滯型;氣滯血瘀型;心陽虛脫型。2.導師認為胸痹心痛病的病程分期可分為三期,其中第二期時心正常的生理功能減弱,自我調(diào)節(jié)恢復功能受限,患者自覺癥狀明顯,通過休息、調(diào)養(yǎng)及生活方式的改變不能緩解病癥,通常選擇就醫(yī)治療,此階段是胸痹心痛病治療的關鍵階段,也是保元養(yǎng)心方形成的基礎及背景。3.導師創(chuàng)立的保元養(yǎng)心方,由保元湯、生脈散、丹參飲、四物湯四方化裁加減而成,主要藥物有:太子參(西洋參或黨參)、黃芪、麥冬、五味子、黃精、赤芍、川芎、丹參、檀香、砂仁、桂枝、炙甘草組成,功用保元益氣,養(yǎng)陰生津,活血化瘀。臨床應用于氣陰兩虛兼血瘀證型的胸痹心痛病較多,臨證加減用藥靈活多變。二、醫(yī)案研究結(jié)果1.收集醫(yī)案中胸痹心痛病的患者,男性26人,女性50人,發(fā)病人群以中老年(50~70歲共64人)居多。2.收集的醫(yī)案中,出現(xiàn)的主要癥狀有:胸悶、氣短、胸痛、失眠、煩躁、乏力倦怠、心慌、頭暈、頭痛、耳鳴、脘腹脹滿、納呆、多汗、便干、四肢麻木、便溏、下肢浮腫、頸項痛、噯氣、腰膝酸軟、畏寒怕冷。3.主要舌象分為以下幾種:舌質(zhì)暗淡苔薄白、舌質(zhì)暗淡苔厚膩、舌質(zhì)暗紅苔薄白、舌質(zhì)暗紅苔厚膩、舌質(zhì)暗紅苔薄膩、舌質(zhì)暗紫有瘀斑苔薄膩、舌質(zhì)暗紫有瘀斑苔薄白、舌質(zhì)淡紅苔薄白、舌質(zhì)暗邊尖紅舌苔薄膩、舌質(zhì)暗邊尖紅苔薄白。以舌質(zhì)暗淡苔薄白最多,占總數(shù)的60.5%。4.主要脈象包括以下幾種:脈弦細、脈沉細、脈弦沉細、脈弦細滑、脈弦沉、脈弦細結(jié)、脈沉、脈弦滑、脈弦細澀、脈弦、脈細數(shù)、脈沉滑、脈沉細結(jié)、脈沉細澀。以脈弦細及脈沉細最多見,分別占總數(shù)的32.4%、22.4%。5.導師運用保元養(yǎng)心方治療的胸痹心痛病基本證型為氣陰兩虛兼血瘀型,兼證證型按由多到少可見氣滯型、痰濕型、瘀熱型、心陽虛弱型、胃氣逆型。6.根據(jù)76例醫(yī)案中出現(xiàn)的藥物統(tǒng)計,共出現(xiàn)藥物106味,出現(xiàn)頻次共1216次,出現(xiàn)頻次最多的藥物是太子參(或以人參、黨參、北沙參、南沙參等代之)、黃芪、麥冬、五味子、檀香、丹參、甘草、茯苓、郁金、白術(shù)、延胡索、廣木香、枳實、焦山楂。7.根據(jù)76例醫(yī)案中出現(xiàn)的藥物分類統(tǒng)計,導師治療氣陰兩虛證型時以補氣藥、活血化瘀藥、理氣藥、補陰藥頻次較高。結(jié)論:1.導師認為胸痹心痛病的病機在于本虛標實,“本虛”是指心臟虛弱受損,外邪侵襲,心脈阻滯而致心痛;“標實”表現(xiàn)為寒凝、氣滯、痰濕、血瘀等,氣陰兩虛貫穿發(fā)病始終。2.在胸痹心痛病的治療過程中以益氣養(yǎng)陰活血為原則貫穿始終,但對病程中存在的其他兼加證型,有針對地加減用藥治療,用藥平緩。3.倡導基本病機、基本治法、基本方藥的統(tǒng)一。4.“不離乎心,不止乎心”注重胸痹心痛病的發(fā)生與肺、脾、肝、腎的關系,整體把握,統(tǒng)籌兼顧。5.醫(yī)囑調(diào)護,關懷病人,順應自然,不妄作勞。
[Abstract]:Objective: Professor Yuan Haibo has been engaged in the research and treatment of traditional Chinese medicine in the past 50 years. He is good at using the theory of traditional Chinese medicine to prevent and treat cardiovascular diseases and related visceral diseases in internal medicine. On the basis of inheriting and carrying forward the experience of predecessors in the treatment of cardiovascular diseases, combining with his own clinical experience in the treatment of this disease, he has established the prescription of protecting the Yuan and nourishing the heart and applied it in clinical practice. This topic through follow-up, exchanges with the teacher, collects and summarizes the medical records, summarizes the tutor's theoretical understanding of chest pain, the establishment of the basic background and theoretical basis of Baoyuan Yangxin Formula, explore the composition of Baoyuan Yangxin Formula, prescription justice and clinical application of the drug. The study of medical records summarizes common symptoms, tongue symptoms, pulse symptoms, concurrent syndromes, frequency of drug use, classification of drug functions, etc., which can help to inherit and develop traditional Chinese medicine. Medical research and other publications, collect detailed reading of the tutor's works and articles, repeated reading, research and thinking, focus on the point, do not know where to consult the tutor, experience the tutor's experience in the diagnosis of chest pain, a preliminary summary of the tutor's general understanding of chest pain and maintenance of the basic background of the heart. Record notes, including tutor's medication experience and talk about the doctor's words, often read the memories, after the key and difficult points are marked, consult the tutor, timely academic discussion and communication with the tutor, carefully record the learning content, and further revise, supplement, improve. 2, medical record research 1. Collection of April 2015 to December 2015 during the period of the tutor's use of the maintenance of the Yuan heart recipe treatment. Under the guidance of the tutor, the seventh edition of internal medicine of traditional Chinese medicine (specialty of traditional Chinese medicine, edited by Zhou Zhongying) was used to diagnose chest pain and heartache, and the medicines appearing in the medical records were classified according to the fifth edition of traditional Chinese medicine textbooks. According to the seventh edition of diagnostics of traditional Chinese medicine (specialty of traditional Chinese medicine, edited by Zhu Wenfeng), referring to the National Science and Technology Support Program of the Eleventh Five-Year Plan, Professor Yuan Haibo's academic thinking and clinical experience observation table, standardize the terminology of original medical records, and transform them into norms. 4. Establish Excel medical records database, according to patient number, sex, age, symptoms, tongue, pulse, syndrome type, treatment, prescriptions and medicines intact input, check the database information repeatedly to ensure the accuracy of information. 5. Use SPSS19.0 software, Excel medical records database data using frequency statistical analysis, statistical application of the insurance element. The distribution of sex, age, symptoms, tongue, pulse, syndrome types, treatment methods, prescriptions and medicines of the patients with chest pain caused by Yangxin Recipe were analyzed. Pathogenic angina pectoris, clinical syndrome focus on the distinction between mild and severe, the tutor thinks that the main causes of chest pain are four aspects: invasion of cold and dampness, damaging Yang injury; diet is not good, phlegm and dampness endogenous; seven internal injury, Qi and blood stasis; fatigue and leisure, loss of spleen. Teachers believe that the course of the disease can be divided into three stages, the second stage of heart normal physiological function weakened, self-regulation recovery function limited, patients with obvious symptoms, through rest, recuperation and lifestyle changes can not alleviate the disease, usually choose medical treatment, this stage is the key stage of the treatment of chest pain, but also Baoyuan Yangxin Formula is the foundation and background of Baoyuan Yangxin Square. 3. The Baoyuan Yangxin Formula is made up of Baoyuan Tang, Shengmai San, Danshen Yin and Siwu Tang. The main medicines are Radix Pseudostellariae (Radix Codonopsis), Radix Astragali, Radix Ophiopogonis, Fructus Schisandrae Chinensis, Radix Paeoniae Rubra, Salvia Miltiorrhizae, Sandalwood Seed, Cinnamomum Cassia Branch and Radix Glycyrrhizae. Yangyin Shengjin, Huoxue Huayu. Clinical application in Qi and Yin deficiency and blood stasis syndrome of chest pain more flexible and changeable. 2, medical records 1. Collection of medical records of chest pain patients, 26 men, 50 women, the incidence of elderly people (50 to 70 years old 64 people) in the majority. 2. Collection of medical records, the main emergence of the main. Symptoms are: chest tightness, shortness of breath, chest pain, insomnia, irritability, fatigue and tiredness, panic, dizziness, headache, tinnitus, abdominal distention, nausea, sweating, dry, numb limbs, stool, lower extremities edema, neck pain, belching, lumbar and knee soreness, chills and chills. 3. The main tongue is divided into the following: dull fur thin white, dull fur thick and greasy tongue, dull red fur thin and white tongue, tongue numbness. The dark red fur is thick and greasy, the dark purple of the tongue has the ecchymosis fur thin and delicate, the dark purple of the tongue has the ecchymosis fur thin and white, the light red fur of the tongue is thin and white, the dark edge of the tongue is pointed red fur thin and delicate, the dark edge of the tongue is pointed red fur thin and white. Pulse string is slippery, pulse string sink, pulse string sink, pulse string slippery, pulse string is astringent, pulse string, pulse number, pulse sink slippery, pulse sink fine knot, pulse sink fine and astringent. The most common type is pulse string and pulse sink fine, accounting for 32.4% and 22.4% of the total respectively. 5. The basic syndrome type of chest pain treated by tutor Baoyuan Yangxin Fang is Qi-Yin Deficiency and blood stasis type. According to the statistics of 76 medical cases, 106 kinds of medicines appeared, 1216 times in total, and the most frequently used medicines were Radix Pseudostellariae (or ginseng, Codonopsis pilosulae, Radix Astragali, Radix Ophiopogonis, Fructus Schisandrae, Sandalwood, Radix Salviae Miltiorrhizae miltiorrhizae, Licorice, Poria, etc.). Ling, Tulip, Atractylodes macrocephala, Corydalis yanhusuo, Hibiscus japonicus, Fructus Aurantii, Hawthorn Jiaoshan. 7. According to the drug classification statistics in 76 cases of medical records, the tutor in the treatment of Qi and Yin deficiency syndrome with Qi-tonifying drugs, blood stasis drugs, Qi-regulating drugs, Yin-tonifying drugs frequency is higher. Conclusion: 1. The tutor believes that the pathogenesis of chest pain is in the deficiency of the real, "this deficiency" refers to the damage of the heart weakness. "Bishi" is characterized by cold coagulation, Qi stagnation, phlegm dampness, blood stasis, etc. Qi and Yin deficiency runs through the onset of the disease from beginning to end. 2. In the treatment of thoracic arthralgia and heartache, the principle of Invigorating Qi and nourishing yin and activating blood circulation runs through the whole process, but for other concurrent syndromes existing in the course of the disease, it is necessary to add and subtract medication, and medication is relieved. 3. Basic pathogenesis, basic treatment, the unification of basic prescriptions and medicines. 4. "Do not leave the heart, not only the heart" pay attention to the occurrence of chest pain and heart disease and lung, spleen, liver, kidney relationship, overall grasp, overall consideration. 5. Medical advice care, care for patients, comply with nature, do not rush to work.
【學位授予單位】：河南中醫(yī)藥大學
【學位級別】：碩士
【學位授予年份】：2016
【分類號】：R256.22

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