就诊科室：生殖男科门诊  Department: Reproductive Men's Clinic
门诊号： 0887101141   Clinic number: 0887101141

姓名：刘宁  Name: Liu Ning
民族：汉族   Ethnicity: Han Chinese
联系电话： 13082172557   Tel: 13082172557

性别：男  Sex: Male
职业：工人   Occupation: Laborer
家庭住址：沧州   Home address: Cangzhou

主诉：左侧阴囊腹股沟血胀不适 1 个月  Complaint: left scrotal inguinal bloody discomfort for 1 month
病史：患者 1 个月前运动出现左侧阴饟腹股沟坠胀不适，休息后症状有所缓解，无尿频，尿痛，尿急和发热等不适。要求检查
History: The patient was exercising 1 month ago and experienced discomfort in the left pubic inguinal groin, which was relieved after resting, with no frequency of urination, painful urination, urgency of urination, or fever. Request for examination
既往史及其它病史：无   Past history and other medical history: none
过敏史：无   Allergy history: none
望闻切诊：患者神态正常，面色稍喑，形体适中，舌质淡，苔薄白；语声正常，气息平和，脉象弦涩。
Examination: the patient has a normal demeanor, slightly ruddy face, moderate body shape, pale tongue, thin white moss; normal speech, calm breath, and stringy pulse.
体格检查：体温： ${36.5}^{\circ }\mathrm{C}$${36.5}^{\circ }\mathrm{C}$36.5^(@)C36.5^{\circ} \mathrm{C} ，心率： 75 次／分，血压： $115/75\mathrm{mmHg}$$115/75\mathrm{mmHg}$115//75mmHg115 / 75 \mathrm{mmHg} ，心肺检查无异常，腹部检查无异常，外生殖器发育无异常，瓦氏动作时左侧精索静脉触诊稍增粗。
Physical examination: temperature: ${36.5}^{\circ }\mathrm{C}$${36.5}^{\circ }\mathrm{C}$36.5^(@)C36.5^{\circ} \mathrm{C} , heart rate: 75 beats/min, blood pressure: $115/75\mathrm{mmHg}$$115/75\mathrm{mmHg}$115//75mmHg115 / 75 \mathrm{mmHg} , no abnormalities on cardiopulmonary examination, no abnormalities on abdominal examination, no abnormalities in external genital development, and a slight thickening of the left spermatic vein on palpation during the Vasovaginal maneuver.
辅助检查：见门诊影像或检验结果   Ancillary tests: see outpatient imaging or test results
辨证依据：患者情绪不畅，肝气郁结，气机不畅，气气滞血撚，精索络脉淤滞而发为筋瘤，脉弦涩为气滞血瘄之象；本病病位在肝肾，辧证为气滞血瘀。
Diagnostic basis: the patient's emotion is not smooth, liver qi is depressed, qi is not smooth, qi is stagnant and blood is twisted, the spermatic cord and veins are stagnant and develop into tendinous tumor, and the pulse is stringy and astringent as a sign of qi stagnation and blood stagnation; the location of this disease is in the liver and kidney, and the evidence of this disease is determined by the stagnation of qi and blood stagnation.
初步诊断－中医证候名称：筋瘤【气滞血㾌证】   Preliminary diagnosis-Name of Chinese medicine syndrome: Tendon tumor [Qi stagnation and blood 㾌 syndrome].
西医诊断名称：精索静脉曲张   Western medical diagnosis name: Varicocele
处理：活血通络，行气止痛。   Treatment: invigorate blood circulation, move Qi and relieve pain.
白术： 12 g 盐泽泻： 12 g 川芳： 12 g 获苓： 12 g
Rhizoma Atractylodis Macrocephalae: 12 g Rhizoma Atractylodis Macrocephalae: 12 g Rhizoma Atractylodis Macrocephalae: 12 g
当归： 15 g 白芍： 30 g 桂枝： 15 g 炒桃仁： 12 g
Radix Angelicae Sinensis: 15 g Radix Paeoniae Alba: 30 g Radix Cinnamomum Cassiae: 15 g Radix et Rhizoma Polygoni Multiflori: 12 g
牡丹皮： 12 g 厚朴： 20 g 清半夏： 12 g 紫苏子： 12 g
Mudanpi: 12 g Houpu: 20 g Qinghansha: 12 g Zisu Zi: 12 g
生姜： 9 g 竹茹： 9 g 浙贝母： 9 g
Ginger: 9 g Bamboo Roots: 9 g Phellodendron Barkley: 9 g
用法：代茶饮，频次：2 次／日   Usage: Drink as tea, frequency: 2 times / day.
地奥司明片，每次用量： 0.45 g ，用法：口服，频次：bid，规格： 0.4
Diosmin Tablets, Dosage: 0.45 g per dose, Usage: Oral, Frequency: BID, Specification: 0.4

就诊科室：生殖男科门诊 门诊号： 0887101141
Department: Reproductive Men's Clinic Clinic No.: 0887101141
$50\mathrm{g}\ast 48$$50\mathrm{g}\ast 48$50g**4850 \mathrm{~g} * 48 片／盒   $50\mathrm{g}\ast 48$$50\mathrm{g}\ast 48$50g**4850 \mathrm{~g} * 48 Tablet/box
塞来昔布胶囊，每次用量： 0.2 g ，用法：口服，频次： qd ，规格： 0.2 $00\mathrm{g}\ast 30$$00\mathrm{g}\ast 30$00g**3000 \mathrm{~g} * 30 粒／盒
Celecoxib Capsules, Dosage: 0.2 g, Usage: Oral, Frequency: qd, Specification: 0.2 $00\mathrm{g}\ast 30$$00\mathrm{g}\ast 30$00g**3000 \mathrm{~g} * 30 capsules / box

医嘱：避风寒，调饮食，适运动，畅情志。少熬夜，忌辛辣，避风寒，慎起居，1月后复诊。
Doctor's advice: avoid wind and cold, regulate diet, appropriate exercise, and smooth emotions. Stay up late, avoid spices, avoid wind and cold, and be careful in daily life. 1 month later, repeat the consultation.