Chief-complaint: Sores in the mouth and tongue, swollen, tender and bleeding gums, painful red eyes
Western-diagnosis: Stomatitis and Conjunctivitis
Medical-history: 38 year old male. Generally very stressed, works long hours, eats junk food almost every day and is always feeling hungry. Has some abdominal discomfort after eating. Usually very thirsty but can’t drink a lot of liquid. Has an odd sleep routine. Is usually constipated and has occasional burning of urine.
Symptoms: In the last 3 days is feeling feverish, constipated, has sores in the mouth and on the tongue, gums are tender, swollen and red. Eyes are puffy, and red. Temperature: 37.7 degrees BP: 130/90mmHg. Blood Sugar: 6.2mmol/l 50 minutes postprandial.
Pulse: Pulse is generally slippery and rapid
Tongue: Red tongue with slimy yellow fur and small ulcerations
CM-diagnosis: Stomach yin vacuity with damp heat
Treatment-principle: Clear heat and eliminate dampness, nourish the stomach and rectify the Qi
Point-prescription: St 4, St44, Sp6, REN3, UB21, LI4
Herb-prescription: Modified: Gan Lu Yin: Sheng Di, Mai Men Dong, Tian Men Dong, Shi Hu, Huang Qin, Gan Cao, Lu Gen, Zhi Mu, Pi Pa Ye, Tai Zi Shen. Colloidal silver mouth wash to which Ban Lan Gen was added, then to swallow.
Lifestyle-prescription: Adequate rest and relation advised. Exercise programme discussed but after settling of the acute stage of illness. Diet advise given especially to avoid sweet foods, fermented foods, acrid, hot, spicy foods, no alcohol.
Results: Patient was reviewed on day 4 after presentation. Mouth and Sores completely resolved. No eye problems. Bowel movements resumed but very loose. Generally much, much better.
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