52 肺膿瘍中醫病例 g/ dl 病例闡述 1. 基本資料 O O *** BMI: kg/m 2 2. 主訴 3. 現病史過去病史 4.1. class II 4.2. CP angl

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1 J Chin Med 28(2): 51-65, 2017 DOI: / 病例報告肺膿瘍合併呼吸衰竭之中西醫會診病例報告 , * 2 1 奇美醫學中心中醫部, 臺南, 臺灣奇美醫學中心加護醫學部, 臺南, 臺灣本病例為 71 歲的女性會診病患, 十日前因呼吸喘促胸悶, 而經急診收入住院, 診斷為肺炎引發肺部膿瘍敗血性休克併發急性呼吸衰竭, 加護病房照護評估暫時難以脫離呼吸器胸腔外科評估因病人年紀偏高體力不佳, 且有食道疝氣病史, 故不建議手術, 持續以抗生素等藥物治療但肺部膿瘍仍未改善而後會診中醫, 初診時病人意識尚清, 面黃暗無華, 身倦乏力, 咳痰無力, 需抽痰, 痰色黃白量多 ; 飲食需以鼻胃管灌食, 舌象因接呼吸器, 故無法配合觀察左脈沉無力, 右脈濡滑數按之無力寸弱辨病為肺癰, 辨證為肺脾腎氣虛, 兼有痰熱蘊肺治以溫補脾肺腎陽氣, 佐以清氣化痰之藥服藥三帖後, 患者神態明顯進步, 再服四帖順利脫離呼吸器, 又三日後, 患者轉入普通病房, 可在攙扶下下床站立步行, 病情持續進步, 而後追蹤胸部 X 光亦顯示肺積水情況改善, 肺膿瘍區塊縮小此病例為中西聯合診治療肺膿瘍之成功案例, 提供給臨床醫師辨證論治的參考關鍵字 : 肺膿瘍肺癰肺脾腎氣虛痰熱蘊肺呼吸衰竭前言 lobe segment pulmonary gangrene (1) (2) (3) (4) 90-95% 75%[1] < 10.0 g/dl > 6 cm 83% 50% 44% [2] * 通訊作者 : # morning2003@gmail.com 105 年 12 月 26 日受理,106 年 3 月 20 日接受刊載

2 52 肺膿瘍中醫病例 g/ dl 病例闡述 1. 基本資料 O O *** BMI: kg/m 2 2. 主訴 3. 現病史過去病史 4.1. class II 4.2. CP angle CyberKnife X 4.6x2.3x3.5cm hiatal hernia X PPI Kyphoplasty ( ) ( ) ( ) 5. 家族及個人史 5.1. nil 中醫四診 6.1. 望診 :

3 許堯欽楊煦星王瑜婷李佳蓉吳孟霖 53 GCS: E4VeM6 9/ 聞診 : PSP mode SpO2:93-99% 6.3. 問診 : X MIP/MEP:- 24/+30 RSI:193.4 cuff leak (+) Xanax 1# Q8H, Mesyrel 1# HS, Etumine 1#HS 237mL 6.4. 切診 : 7. 實驗室檢查 7.1. 過往檢驗數據 : ( ) Uric acid 7.6mg/dL ( ) CA U/mL CA U/Ml SCC antigen 0.5ng/ ml CEA 3.0ng/mL ( ) Lung function test small airway obstruction FEV1/FVC 60% ( ) Interstitial fibrosis, inflammatory cell infiltration. No granuloma or tumor is seen. No microorganism is identified 此次住院檢驗數據 : ( ) Klebsiella pneumonia ( ) Thick basal septum with dilated LA, adeuate LVP, aortic valve calcification with subvalvular and valvuar stenosis ( ) Systolic anterior motion of anterior mitral leaflet and left ventricular outflow tract obstruction

54 肺膿瘍中醫病例表一血液檢驗數據項目 / 日期 104/03/23 09/07 09/10 09/14 09/17 RBC (/ul) 3.49*10 6 3.93*10 6 Hb (g/dl) 9.9 10.5 7.2 7.0 7.

6 WBC (ul) 9900 36500 25900 15400 13300 Neutrophils band (%) 1.0 0 0 0 0 Segmented (%) 68.1 77.1 89.5 88.6 91.4 Lymphocytes (%) 19.2 7.6 1.9 7.6 5.

4 54 肺膿瘍中醫病例表一血液檢驗數據項目 / 日期 104/03/23 09/07 09/10 09/14 09/17 RBC (/ul) 3.49* *10 6 Hb (g/dl) Platelet (/ul) 422* * * * *10 3 CRP (mg/l) WBC (ul) Neutrophils band (%) Segmented (%) Lymphocytes (%) Monocytes (%) Eosinophils (%) Basophils (%) ( ) BUN: 13mg/dL Creatinine: 0.64mg/dL Na: 128.1mmol/L K: 3.88mmol/L AST: 12U/L ALT: 11U/L albumin: 2.7g/dL ( ) ( ) X ( ) 圖一入院時影像學檢查

5 許堯欽楊煦星王瑜婷李佳蓉吳孟霖時序圖 ( 圖二 ) 圖二時序圖 9. 理法病機分析 CRP WBC 10. 理法病機分析 ( 圖三 ) 11. 診斷治則 12.1.

6 56 肺膿瘍中醫病例圖三病因病機圖表二西醫用藥簡表藥名劑量用量頻次備註 Carvedilol 6.25mg 1#PO BID Perinodopril 4mg 0.5#PO QD Nicorandil 5mg 1#PO BID Metoclopramide 9.08mg/2mL IVP Q12H Dimethicone 40mg 2#PO QID Acetylcysteine 200mg/3g 3#/PO BID Acetaminophen 500mg 1#PO Q8H Tramadol 50mg 1#PO Q8H Tazocin 2.25mg/V 2V/IVF Q6H Alprazolam 0.5mg 1#PO Q8H Clotiapine 40mg 1#PO HS Trazodone 50mg 1#PO HS Prednisolone 5mg 2#PO BID

7 許堯欽楊煦星王瑜婷李佳蓉吳孟霖方藥 400mL 14. 方藥分析 15. 追蹤診療紀錄 ( 表三 ) 生化檢查數據及胸部 X 光片變化 : 表三追蹤診療紀錄看診日期病歷處方 ( 單位 : 錢 ) CT lung abscess GCS E4VeM6 BP: /98-117mmHg 9/17 WBC:13300/uL Hb:7.0mg/dL (9/14-9/17) SpO 2 :93-95% 09/17 PSP mode SpO 2 :93-99% MIP/MEP:-24/+30 RSI:193.4 cuff leak (+) RSBI< RSBI< TID* lactulose 9/21 WBC 16300/uL Hb 7.2mg/dL : TID*2

8 58 肺膿瘍中醫病例看診日期病歷處方 ( 單位 : 錢 ) /24 MIP/MEP +40/-72 RSI cuff leak (2+) BP /90-114mmHg 9/21 WBC 16300/uL Hb 7.2mg/dL (9/18-9/24) SpO % T-piece 28% room-air Chest X-ray GCS E4V5M6 TPR 36.7/86/27 BP 151/102 mmhg 9/24 WBC 10900/uL Hb 8.4mg/dL 09/25 9/ bedside Chest X-ray GCS E4V5M6 BP /88-115mmHg 9/28 WBC 12100/uL Hb 10.4 mg/dl (9/25-9/28) SpO % TID* TID* TID* mg/ dl 7.0mg/dL 10.4mg/ dl

9 許堯欽楊煦星王瑜婷李佳蓉吳孟霖 59 圖四血色素變化圖五白血球分類計數 segment 變化圖六 C 反應蛋白 (CRP) 變化

60 肺膿瘍中醫病例 15.1.2. Segment 77.1% 91.4% 76.4% 15.1.3. CRP 156.

in the bilateral lungs probably due to pneumonia.

10 60 肺膿瘍中醫病例 Segment 77.1% 91.4% 76.4% CRP 156.4mg/L 51.6mg/L 11.2mg/L 胸部 X 光片 :( 圖七 ) / /21 9/24 9/28 9/16 9/21 9/24 9/28 9/16 Patchy consolidations in the bilateral lungs probably due to pneumonia. Left complicated parapneumonic effusion or empyema. 9/21 Cardiomegaly with pulmonary edema pattern with bil. pleural effusion. Especial L't. Left side middle lung focal atelectasis. Visible L-spine s/p bone cement injection. 圖七治療前後胸部 X 光片變化討論一西醫診療肺膿瘍 [3] (1) (2) (3) (4) (1) 6 cm (2) (3)

11 許堯欽楊煦星王瑜婷李佳蓉吳孟霖 61 (4) (5) (6) % 75% < 10.0 g/dl > 6 cm 83% 50% 44% g/dl 二肺膿瘍近似中醫所曰肺癰 : [4] [5] [6] [7] [8] [9] 三老中醫治療肺膿瘍之經驗 :

12 62 肺膿瘍中醫病例 [10] [11] [12] 四本案例所使用之中藥對肺膿瘍的現代醫學研究 helper T cells suppressor T cells [13] Hela cells B HIV [14,15] -

13 許堯欽楊煦星王瑜婷李佳蓉吳孟霖 63 [16] 五本案例證治之心得與體會結論 71 X 參考文獻 1. Pohlson EC, McNamara JJ and Char C, etc. Lung abscess: a changing pattern of the disease. Am J

14 64 肺膿瘍中醫病例 Surg., 150:97-101, Hirshberg B, Sklair-Levi M and Nir-Paz R, etc. Factors predicting mortality of patients with lung abscess. Chest., 115: , :35-41, :15-16, : , pp , pp , ZY/T , :9-10, : , 佀 55: , :1-15, pp. 587, : , pp. 390, 1999

15 J Chin Med 28(2): 51-65, 2017 DOI: / Case Report Lung Abscess with Respiratory Failure was Treated by Combination of Western and Traditional Chinese Medicine: A Case Report Yao-Chin Hsu 1, Hsi-Hsing Yang 2, Yu-Ting Wang 1, Chia-Jung Lee 1, Meng-Lin Wu 1, * 1 Department of Chinese Medicine, Chi-Mei Medical Center, Tainan, Taiwan 2 Department of Intensive Care Medicine, Chi Mei Medical Center, Tainan, Taiwan This 71-year-old female came to ER with complaint of shortness of breath and chest tightness. After evaluation, the patient was admitted with diagnosis of pneumonia induced lung abscess, sepsis shock and acute lung failure. Due to the age, general weakness and the history of esophagus hernia surgery, chest surgeon recommended antibiotics therapy instead of operation. However, the situation wasn't improved therefore they consulted Chinese Medicine. At the first evaluation, the patient was in unclear conscious, yellow and lusterless facial complexion, tongue inspection was not performed due to the respirator, in addition to general weakness, difficult expectoration with a large amount of yellowish sputum, formula milk diet with nasal-gastric tube. Pulse examination: left pulse sunken-weak and right pulse rapid, slippery. Under the diagnosis of lung-spleen-kidney qi vacuity with phlegm-heat of lung, we prescribed Chinese medicine for supplementing qi, clearing and dispelling heat-phlegm. after three days, the inspection was more spirited, then we added yang-warming medicine for four more days and the patient successfully weaned off the respirator. Three days later, she was transferred into general ward. Following up the chest X-ray, the pulmonary edema was significantly decreased, also the range of lung abscess. This is a case successfully treated with both western and Chinese medicine, in the hope to provide some opinions for clinical doctors. Key words: Lung abscess, Lung-spleen-kidney qi vacuity, Respiratory failure, Phlegmheat of lung *Correspondence author: Meng-Lin Wu, Department of Chinese Medicine, Chi-Mei Medical Center, No.901, Zhonghua Rd., Yongkang Dist., Tainan City 710, Taiwan, Tel: ext.53784, morning2003@gmail.com Received 26 th December 2016, accepted 20 th March 2017

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<4D F736F F D20B867A6E6AB79A6E5A4A4C2E5AA76C0F8AF66A8D2B3F8A7695FB3AFA9C9A4E55F2E646F63> 224 台灣中醫臨床醫學雜誌 2008:14(3) 經行咳血中醫治療病例報告陳怡文奇美醫學中心中醫部摘要本案例 25 歲的林小姐, 自 95 年 12 月開始每逢經期即出現咳血的症狀, 經成大醫院電腦斷層檢查, 診斷為肺子宮內膜異位症從中醫的

52 肺膿瘍中醫病例 g/ dl 病例闡述 1. 基本資料 O O *** BMI: kg/m 2 2. 主訴 3. 現病史 過去病史 4.1. class II 4.2. CP angl

52 肺膿瘍中醫病例 g/ dl 病例闡述 1. 基本資料 O O *** BMI: kg/m 2 2. 主訴 3. 現病史過去病史 4.1. class II 4.2. CP angl