Case 1 : Pneumonia combining with Myocarditis ( 《中医历代医案精选》 TCM Clinical Cases Collection , P780)
Liu, boy, 2 years old. 14.06.1971 in hospital, diagnosed as Pneumonia combining with Myocarditis. On 21.06’s consultation, high fever, cold and heat alternatively, slight cough, short of breath, constipation.
Inspection : body temperature 39.1˚C, pale complexion, eyelid and lower limbs swelling, cold limbs, heart rate 165 per minute, rale, soft abdomen, light tongue body, slight white coating, wiry-thready-weak-rapid pulse.
Syndrome differenciation and treatment: wind-heat invasion of lung, evil stay at shaoyang, vital qi deficiency. Apply xiaochaihu decoction to harmonize pivot, support vital qi and eliminate evil qi.
Formula: chaihu 4.7 g, banxia 4.7g, taizishen 4.7g, gancao 3g, huangqin 9g, qinghao 4.7g
23.06. second visit: fever went down the day before, bowel movement goes, energy and appetite normal, pale complexion better, cough down, pharynx slight red. Formula as before, off chaihu, add maidong 6g, for 3 more days
26.06 third visit: temperature normal, symptoms disappear, lung normal.
Case 2: Congenital Heart Disease, complicated by pneumonia ( 《蒲辅周医案》Pufuzhou Clinical cases, P140)
Xiao, girl, 1y. starting from high fever, she has been asthmatic breathing for 5 days, went to one hospital on 26/04/1960. After hospitalized, she has been checked blood, lung, etc. and diagnosed as Congenital Heart Disease, complicated by pneumonia.
Course of disease and treatment: treating for 3 days, no improvement, invite Mr. Pu for consultation. She has high fever without sweating, asthmatic breathing and dysphoria, coughing without sound, short of breath, fullness under heart, dull complexion, light tongue, greasy and slight grey coating, deep, weak and rapid pulse. This is due to congenital weakness plus new evil attacking lung, new and old disease combined together. Treatment should to strengthen heart as Ben, to treat lung as Biao.
Formula as: guizhi 0.5g, zhigancao 0.5g, yuanzhi 3g, fried suzi 3g, xinren 3g, juhong 3g, shengjiang 2 pieces, dazao 1, 2 packs.
On 1/05 for the second visit: only cough reduced, others as usual. Take off suzi, xinren, add shashen 6g, tiandong 6g, wuweizi 10 granule, 2 packs. Combined with 2 times plasma transfusion, high fever going down, cough improved further, not asthmatic breathing. Finally, regulate lung and stomach, strengthen heart and tonify qi for a better ending.