I don’t know what happened this week, but I encountered some strange fevers. I have extracted three online medical records for your discussion.
An elderly male, one year after lung cancer surgery, with extensive metastasis. A recent CT scan showed diffuse thickening of the colon wall, indicating the possibility of ulcerative colitis. He had a fever three days ago, not exceeding 39°C, more severe at night, extreme fatigue, anorexia, borborygmus and abdominal pain, loose stools, and anuria. He had been hospitalized for treatment without improvement. The hospital stated there was no cure. Currently, no dry mouth or bitter taste; tongue red with a thin coating, brownish in the center and moist.
Comprehensive assessment indicated yang qi on the verge of detachment, so a combination of Sini Decoction and Zhuling Decoction was proposed. The prescription is as follows:
Shichangpu (Acorus) 15g, Zhuling (Polyporus) 15g, Fuling (Poria) 15g, Zexie (Alisma) 15g, Huashi (Talc) 15g, Danpi (Moutan Bark) 10g, Ejiao (Donkey-hide Gelatin) 10g (melted), Dahuang (Rhubarb) 10g, Zhigancao (Honey-fried Licorice) 10g, Zhifuzi (Prepared Aconite) 10g, Ganjiang (Dried Ginger) 6g, Wuzhuyu (Evodia) 6g, Huanglian (Coptis) 3g, Muxiang (Costus Root) 3g.
2 doses, decocted in water and taken orally.
On the second day, the patient’s family reported that the fever had subsided after taking the medicine, though other symptoms had not improved significantly. They were advised to stop the medication. Four days later, during a follow-up consultation, the patient’s body temperature remained normal, indicating that the yang qi had been stabilized and there was still a glimmer of hope. Other treatment methods were then discussed.
The pathogenesis of this case is complex and very challenging, so we will not analyze it in detail here.
An elderly male with long-standing Alzheimer’s disease, unable to care for himself. One month ago, he began developing fevers every afternoon or evening, around 37.5°C, with phlegm in the lungs. He had been hospitalized at a local Class A TCM hospital without significant improvement. Over the past week, morning fevers were added to the pattern. The hospital stated they had no further medication to offer. Currently: tongue red, coating slightly yellow, thick, greasy and somewhat dry in the center; feeding via nasal tube; stools initially dry then loose.
Initial consideration was qi-yin deficiency fever. A modified Buzhong Yiqi Decoction was proposed:
Raw Huangqi (Astragalus) 15g, Renshen (Ginseng) 15g, Zhigancao (Honey-fried Licorice) 15g, Raw Baizhu (Atractylodes) 10g, Chenpi (Tangerine Peel) 6g, Danggui (Angelica) 10g, Shengma (Cimicifuga) 6g, Chaihu (Bupleurum) 12g, Zhimu (Anemarrhena) 15g, Qinghao (Artemisia) 15g.
3 doses, 50ml per nasal feeding, every three hours.
After administration, the nighttime temperature dropped that same day. The second day remained at the same level as the first. On the third day, the temperature rose rapidly during the daytime, reaching 38.3°C at noon — a sign that the upright qi had recovered. The patient was advised not to worry; the temperature would naturally resolve in the afternoon, and indeed it began to drop after 5 PM. After comprehensive reassessment, Taizishen replaced Renshen in the original formula, combined with a modified Shengjiang San. The second-visit prescription:
Raw Huangqi 15g, Taizishen (Pseudostellaria) 15g, Zhigancao 15g, Raw Baizhu 10g, Chenpi 6g, Danggui 10g, Shengma 6g, Chaihu 6g, Zhimu 15g, Qinghao 15g (added last), Chaojiangcan (Stir-fried Silkworm) 6g, Chantui (Cicada Slough) 6g, Jianghuang (Turmeric) 6g, Dahuang 6g, Yinchaihu (Stellaria Root) 6g, Digupi (Wolfberry Bark) 6g.
3 doses, 50ml per nasal feeding, every three hours.
After this formula, the temperature gradually declined and was essentially normal after three days. A large amount of phlegm was expelled from the lungs, and after evaluation, the patient was discharged. Post-discharge, there were brief episodes of elevated temperature. Upon inquiring about the patient’s daily diet, it was discovered that the family had been feeding beef daily to improve nutrition — a major dietary taboo in internal-injury fever. They were advised to stop the beef, and no further fever occurred.
This case has a complex pathogenesis and is a true test of clinical skill, so we will not analyze it in detail. Discussion is welcome in the comments. Notably, the patient was staying at a TCM hospital, yet the hospital did not prescribe Chinese herbal medicine — predictably, they dispensed powdered Sanyeqing and a patent formula for clearing heat and resolving the exterior. They didn’t even use Chaihu. Truly disappointing.
Fever began four days ago: 38°C on days 1 and 2. On day 2, a strong positive test (first COVID infection) was confirmed, and Pfizer Paxlovid was started. On days 3 and 4, the fever reached 39°C; whether antipyretics were taken is unknown. Currently: aversion to cold, no sweating, no headache or body aches, severe sore throat, minimal cough with scant greyish-white sputum, loose stools on day 3 but otherwise no bowel movements, poor appetite, excessive sleepiness. Tongue: enlarged with teeth marks, underlying redness, white thick greasy coating (stained by throat spray).
Based on symptom presentation, this was judged as a fairly typical Shaoyin fever with Shaoyin sore throat. A modified Mahuang Fuzi Xixin Decoction combined with Banxia San was proposed:
Mahuang (Ephedra) 15g (decocted first), Fupian (Aconite Lateral Root) 15g, Xixin (Asarum) 9g, Qingbanxia (Processed Pinellia) 9g, Zhigancao 6g, Guizhi (Cinnamon Twig) 6g.
Instructed to decoct for one hour, take 100ml per dose, every four hours, and stop once fever resolves.
After taking one dose at 10 PM that evening, the fever resolved. The next day, temperature was normal, but the sore throat had not significantly improved — so severe that the patient could not speak. No cough but with sputum, white with yellowish tinge, fatigue, and diarrhea after eating. After considering epidemic factors, a modified Mahuang Shengma Decoction was proposed:
Mahuang 10g (decocted first), Shengma (Cimicifuga) 10g, Danggui 6g, Zhimu 6g, Huangqin (Scutellaria) 6g, Yuzhu (Solomon’s Seal) 3g, Raw Baishao (White Peony) 3g, Tianmendong (Asparagus Root) 3g, Guizhi 6g, Fuling 10g, Zhigancao 10g, Ganjiang 3g, Chaihu 6g, Jiegeng (Platycodon) 10g, Fuchaobaizhu (Stir-fried Atractylodes with Bran) 10g, Renshen 3g.
3 doses, decocted in water and taken orally.
This case is quite puzzling. Is it a Shaoyin or Jueyin pattern? Is there a clear transmission and boundary between the two? Could other theoretical frameworks explain and predict the progression? Since the second-visit prescription was just started, the efficacy is unknown and analysis is not yet possible. Your insights are welcome.
中文原文 / Chinese Original
这一周不知道怎么了，净遇到些奇奇怪怪的发热，摘取三例网诊病案供诸位探讨。
老年男性，肺癌术后1年，广泛转移，近期CT显示结肠肠壁弥漫增厚，溃疡性结肠炎可能，三日前发热，未超过39度，夜间重，极度乏力，纳差，肠鸣腹痛，大便稀，无尿，始终住院治疗，无效，医院称已无药可治，刻下无口干口苦，舌红苔薄中间呈褐色，苔润（图片见微信公众号，本站存储空间已不足）。
综合考虑为阳气欲脱，拟四逆汤合猪苓汤加减，处方如下：
石菖蒲15 猪苓15 茯苓15 泽泻15 滑石15 丹皮10 阿胶10（烊化） 大黄10 炙甘草10 制附子10 干姜6 吴茱萸6 黄连3 木香3
2付，水煎服
第二日患者家属报告称服后已退烧，其余症状无明显改善，嘱停服。再过四日后面诊，期间体温正常，说明阳气已固，尚有一线生机，另议他法调治。
本案病机复杂，十分考验水平，不再详细分析。
老年男性，阿尔茨海默病多年，生活不能自理，一个月开始每天下午或者晚上发热，37.5左右，肺里有痰，已在当地三甲中医医院住院治疗，无明显改善，近一周开始增加上午发热，医院亦表示已无药可用，刻下舌红，苔中部略黄厚腻，偏干，鼻饲进食，大便先干后稀。
首先考虑为气阴两虚发热，拟补中益气汤加减，处方如下：
生黄芪 15g 人参 15g 炙甘草 15g 生白术 10g 陈皮 6g 当归 10g 升麻 6g 柴胡 12g 知母 15g 青蒿 15g
三付，每次鼻饲50ml，三小时灌一次。
服后当日夜间体温下降，第二日与前日持平，第三日白天出现体温快速升高，12时达到38.3°，此为正气已复，嘱患者不用着急，下午体温自会恢复，17时后开始回落。综合考虑，以前方太子参易人参，合升降散加减，二诊处方如下：
生黄芪 15g 太子参 15g 炙甘草 15g 生白术 10g 陈皮 6g 当归 10g 升麻 6g 柴胡 6g 知母 15g 青蒿 15g（后下） 炒僵蚕 6g 蝉蜕 6g 姜黄 6g 大黄 6g 银柴胡 6g 地骨皮 6g
三付，每次鼻饲50ml，三小时灌一次。
此方服后体温缓慢下降，三日后已基本正常，肺中痰涎排出甚多，经评估办理出院。出院后体温仍有短期升高，询问患者日常饮食起居，发现其家属为了增加营养每日均喂食牛肉，此乃内伤发热饮食之大忌，嘱停服牛肉，后再未见发热。
本案病机复杂，亦十分考验水平，不再详细分析，欢迎评论区讨论。此案病人住在中医院，医院并没有给用中药，不出意料开了三叶青粉和解表清热颗粒，连柴胡都没上，真是差劲。
四日前发热，第1、2天38℃，第2天测出强阳（为首阳）起开始服用辉瑞Paxlovid，第3、4天39℃，是否服用退烧药未知。刻下怕冷无汗，无头身疼，咽痛甚，咳嗽不多、痰少灰白色，第三日便稀，其余时间无便，纳差，嗜睡，舌胖大有齿痕，质隐红，苔白厚腻（喷喉药染色）。
根据症状表现判断为比较典型的少阴发热及少阴咽痛，拟麻黄附子细辛汤合半夏散及汤加减，处方如下：
麻黄 15g（先煎）附片 15g 细辛 9g 清半夏 9g 炙甘草 6g 桂枝 6g
嘱煎煮一小时，每次服用100ml，四小时一次，退热停服。
当晚十时服用一次后即退热，第二日体温正常，但咽痛无明显好转，咽痛不能说话，不咳嗽有痰，痰色白中带黄，乏力，吃饭后腹泻，综合考虑时疫因素后拟麻黄升麻汤加减，处方如下：
麻黄 10g（先煎）升麻 10g 当归 6g 知母 6g 黄芩 6g 玉竹 3g 生白芍 3g 天冬 3g 桂枝 6g 茯苓 10g 炙甘草 10g 干姜 3g 柴胡 6g 桔梗 10g 麸炒白术 10g 人参 3g
3付，水煎服
本案甚是蹊跷，究竟是少阴还是厥阴？二者是否有明显的传变和界限？用其他思路是否能够解释和预测？由于刚服用二诊处方，疗效未知，目前尚无法分析，欢迎给出高见。
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