
Name: Hu.
Sex: Female.
Age: 20 years.
Occupation: A college student.
Chief Complaint: Redness and swelling-pain of eyes for 2 days.
History of Present Illness: Two days ago, the patient got cough and rhinorrhea resulting from catching a cold, she went to the local policlinic and then was treated with "GanMaoTong, SMZ" and so on. 20 minutes later after eating "SMZ" ,the patient got a sudden uncomfortable sensation of whole body, accompanied by immediate redness and swelling pain of her eyes, photophobia and lacrimation. Then she quickly went to the policlinic and was treated with "Tab. Astemizoli" and "Guttae Hydrocortisoni. " After 2 days of the above treatment, the uncomfortable sensation of whole body was relieved greatly, but photophobia, lacrimation and swelling pain of eyes were not relieved effectively. Because it's close on her end of term examination, meanwhile the sickness stopped her from studying for the examination, then she was urgent for restoration to health. Then she came here for treatment on June 18,1996.
Physical Examination: The patient was conscious with a normal general condition. The conjunctivas of both eyes were obviously congestive, accompanied with photophobia and lacrimation. The patient wiped her tears with a handkerchief constantly. The pulse was thready and floating. The tongue was red with a thin layer of white fur. There wasn't other abnormal sign.
Diagnosis: Acute Allergic Conjunctivitis.
Differentiation: It's caused by attack of exogenous wind-heat, which was followed by the internal production of allergic drug poison. Both endogenous and exogenous pathogenic factors got entangled each other, and then turned into pathogenic fire in the body, moreover flamed upward to the eyes. Then the eyes became red and swollen.
Therapeutic Principle: Clearing away heat and sending the pathogenic fire down; cooling blood and eliminating toxic material, expelling pathogenic wind and relieving the superficies-syndrome.
Recipe :
ShengDiHuang,Dried Rehmannia Root
ZiCao,Arnebia Root
HuangLian,Coptis Root
CheQiangZi,Plantain Seed
JingYinHua, Honeysuckle Flower
HuangQing,Scutellaria Root
ZhiZi,Capejasmine Fruit
JueMingZi,Cassia Seed
LongDanCao,Gentian Root
Boric,Peppermint Herb
ChanYi,Cicada
ShengGanCao,Raw Liquorice Root
All the above drugs were to be decocted in water for oral taking. 3 doses were prescribed.