乾燥症之中醫舌脈診持續評估病例報告

Continuous Evaluation of Sicca Complex using Traditional Chinese Medicine Tongue and Pulse Diagnosis: A Case Report

69歲男性患有乾燥症（Sicca Complex）伴隨雙眼巨細胞病毒性虹彩炎，患者於2021年8月至臺北榮民總醫院傳統醫學部中醫內科門診就診，主訴近一年半有口腔黏膜糜爛、舌頭刺痛感、眼乾澀紅腫，且隨壓力大、情緒激動或食用燥熱食物時加重。中醫辨證為津液虧虛、熱毒熾盛、肝鬱脾虛，治則為養陰潤燥、清熱解毒、疏肝健脾。持續治療並追蹤3個月後，有效改善患者口腔與眼睛乾澀感、口腔黏膜糜爛，舌頭刺痛感，雙眼紅腫癢，及使用人工淚液與消炎眼藥水頻率皆下降。本病歷報告藉由科學化舌診與脈診儀器持續性觀察乾燥症患者舌脈診的連續性改變，與評估證型與病機的變化。加上辨證論治、隨證治療，可有效改善諸症，希冀能提供中醫利用舌脈診輔助診斷治療乾燥症之經驗，以供中醫實證醫學指引。

A 69-year-old man with Sicca complex combined with bilateral cytomegalovirus iritis suffered from oral mucous ulcers, tingling of the tongue and dry, red eyes, which aggravated by stress, emotional agitation, or spicy food consumption. In August 2021, the patient visited Taipei Veterans General Hospital for Tradition Chinese Medicine(TCM) therapy. The TCM pattern differentiation included“Fluid deficiency”,“Excessive heat and toxin”,“Liver stagnation and spleen deficiency”; which the TCM treatment was“Nourish yin and moisten dryness”,“Clear heat and resolve toxin”, and“Course the liver and fortify the spleen”. During the three-month treatment period, we had used TCM tongue and pulse diagnosis equipment to follow-up the patient’s clinical condition, which had shown improvement of dryness of the month and eyes, oral ulcers, and tingling sensation of the tongue; moreover, decreased frequency of redness and itching in both eyes, and frequency of using artificial tears and anti-inflammatory eye drops were noted. Therefore, the use of TCM to treat Sicca complex could effectively improve various dryness symptoms. This case report of using continuous tongue and pulse diagnosis equipments to monitor the disease changes could provide evidence-based practice in TCM.