
Name: Hou.
Sex : Male.
Age: 20 years.
Occupation: A college student.
Chief Complaint: Redness and swelling of eyes for half a month, accompanied with photophobia and lacrimation.
History of Present Illness: Half a month ago, the patient's eyes became red and swollen without obvious causes. There was swelling-pain in the eyes accompanied with photophobia, lacrimation and much secretion of eyes. He went to the local policlinic and then was treated with "eye drops of anti-inflammatory, Guttae Cephamandole, Spiramycin" and "powder of BanLanGeng" for half a month. But there was no obvious curative effect on him. The illness stopped him from reading and studying. Then he came here for treatment on November 10, 1996.
Physical Examination: The patient was conscious with a normal general condition. The conjunctivas of both eyes were severely congestive, the tarsuses were congestive and swollen, accompanied with constant lacrimation. The pulse was floating and rapid. The tongue was fresh red with a thick layer of white fur. There wasn't other abnormal sign.
Diagnosis: Acute Conjunctivitis.
Differentiation: It was caused by exogenous wind-heat and dampness-evil, they got entangled each other and turned into pathogenic fire in the body, which flamed upward to the eyes and then the eyes were hurt.
Therapeutic Principle: Expelling wind and clearing away heat; expelling dampness and sending the pathogenic fire downward; expelling the toxic material with purgative herb.
Recipe :
ShengDiHuang,Dried Rehmannia Root
HuangLian,Coptis Root
CheQianZi,Plantain Seed
JueMingZi,Cassia Seed
ZhiZi,Capejasmine Fruit
HuangQin,Scutellaria Root
XiaKuCao,Prunella Spike
LongDanCao,Gentian Root
Boric,Peppermint Herb
ChanYi,Cicada
ShengDaHuang,Raw Rhubarb
All the above drugs were to be decocted in water for oral taking. 2 doses were prescribed. Hot and greasy food was forbidden.
Effect Observation: During the treatment, some foul mucous stools were moved for several times, then the redness and swelling of the eyes disappeared at all, photophobia and lacrimation disappeared too. Then it's ending.