History of Present Illness: Six days ago, the patient got sore throat and a fever due to catching a cold, accompanied with chill, anorexia, nausea. Then he was led to hospital for treatment, it was diagnosed as "Acute Tonsillitis" and he was treated by intramuscular injecting "Benzylpenicillin" and oral taking some "antibiotics. "After 6 days' treatment, the fever and the soreness of throat couldn't be relieved yet, the nausea and the anorexia became more severe. 1 hour ago, the patient got a sudden abdominal pain. Then his grandfather asked me for treatment on August 20,1996.
Physical Examination: The patient was conscious with a weak general condition. The pulse was thready and rapid. The tip of the tongue was fresh red, the body of the tongue was covered with a thick layer of whitish, watery fur. Both tonsils were swelling with purulent exudate attached. The mucous membrane of the retropharyngeal wall was congestive obviously. There was tenderness in the middle abdominal region. When touched upon, the whole body was hotter than normal, because there was no clinical thermometer at that time, the concrete temperature was unknown. There wasn't other abnormal sign.
Diagnosis: Acute Tonsillitis with Complication of Acute Gastritis.
Differentiation: It was caused by exogenous wind-heat that attacked the throat and endogenous cold dampness that was retained in the stomach. In TCM, it was characteristical syndrome of heat in the upper while cold in the lower.
Therapeutic Principle: Warming therapy and heat clearing therapy should be used together in order to clear away wind heat in the upper and eliminate cold-dampness in the lower.
Recipe:
ShengShiGao,Gypsum 30g (to be decocted earlier)
ZhiMu,Windweed Rhizome 10g
ShengDiHuang,Dried Rehmannia Root 20g
HuangLian,Coptis Root 10g
HuangQin,Scutellaria Root 10g
FaBanXia,Pinellia Tuber 8g
PaoJiang,Baked Ginger fig
CangZhu, Atractylodes Rhizome 15g
HuoXiang, Agastache 10g
PeiLan, Eupatorium 10g
ChanYi,Cicada Slough 10g
BaiJiangCan,Batryticated Silkworm 10g
ShengGanCao,Raw Liquorice Root 6g
All the above drugs were to be decocted in water for oral taking. 2 doses were prescribed. Greasy, cold and hot food was forbidden during the treatment.
Effect Observation: After taking the 1st dose, the fever and the soreness of throat disappeared at once, the nausea and the abdominal pain disappeared too. I told him to continue taking the 2nd dose. After taking the 2nd dose, there was no uncomfortable sensation any more, the patient could play freely.
