
Name: Zhou.
Sex : Male.
Age: 34 years.
Occupation: A peasant.
Chief Complaint: Sore throat and chest distress for 3 days.
History of Present Illness: Three days ago, the patient got a pain and a sensation of being obstructed in the throat. It seemed that something obstucted his throat when he was breathing, it was accompanied with chest destress, shortness of breath. It's not followed by high fever, cough and profuse sputum. Swallowing could aggravate the soreness. Then he asked me for treatment on August 18,1996. In addition, he had been used to smoking for more than E0 years.
Physical Examination: The patient was conscious with a normal general condition. The pulse was thready and floating. The tongue was dark red with a dry layer of yellowish fur. There was diffuse congestion in the mucous membrane of the pharyngeal wall, and there were hyperplasis of lymphoid follicles in the retropharyngeal wall. It was dark red in colour. Both tonsils were swelling(Ⅱ°). There wasn't other abnormal sign.
Diagnosis: Acute Bout of Chronic Pharyngitis.
Differentiation: It's pharyngeal fluid had been fumigated by smoking for a long time, it caused pharyngeal wall was dry and rough, so that there was qi stagnation and blood stasis in the throat, which caused there appeared hyperplasis of lymphoid follicles in the throat. Furthermore it disturbed the normal functional activities of the lung-qi, then the patient got the sore throat and chest distress.
Therapeutic Principle: Nourishing Yin and promoting the production of the body fluid, clearing away pathogenic factor to ease throat, activating blood to resolve stasis, smoothing the chest oppression and regulating qi, and it's most important for the patient to give up his bad habit of smoking.
Recipe :
ShengDiHuang,Dried Rehmannia Root
TianMenDong, Asparagus Root
XuanShen, Scrophularia Root
BaiJiangCan, Batryticated Silkworm
ChanYi,Cicada
JiangHuang, Turmeric Rhizome
JieGeng,Platycodon Root
SheGan,Belamcanda Rhizome
ShuiZhi,Dried Leech
BaiQian,Swallowwort Rhizome
QuanGuaLou,Trichosanthes Fruit
ShengGanCao,Raw Licorice Root
All the above drugs were to be decocted in water for oral taking. 5 doses were prescribed. He was told to stop drinking and smoking. Greasy and hot food was forbidden during the treatment.
Effect Observation: After taking the 1st dose, the soreness of throat disappeared immediately, the sensation of being obstructed in the throat and the chest distress were relieved. After 5 days of the above treatment, chest distress and shortness of breathing disappeared too. After 1 month' s follow-up, the sickness didn' t recur. Then it's ending.