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The “Ten Questions Song” states: “First ask about cold and heat, second ask about sweating, third ask about head and body, fourth ask about bowel movements, fifth ask about diet, sixth ask about the chest, seventh ask about deafness and thirst, eighth ask about old illnesses and causes, and also consider medication changes; for women, it is essential to ask about menstrual periods, delays, early or excessive bleeding can all be seen; add a few words for pediatrics, smallpox and measles are all included in the examination.”
(1) Ask about Cold and Heat
Asking about cold and heat involves inquiring whether the patient has feelings of cold or heat. Cold refers to the sensation of being cold; heat refers to fever. If the patient’s body temperature is higher than normal, or if they feel heat in the body or locally, it is termed fever. The occurrence of cold and heat mainly depends on the nature of the pathogenic factor and the balance of Yin and Yang in the body. Therefore, by asking about the patient’s feelings of cold and heat, one can discern the nature of the disease’s cold or heat characteristics and the state of Yin and Yang.
Cold and heat are common clinical symptoms, and during the inquiry, attention should be paid to whether the patient feels cold or hot, whether they occur separately or simultaneously, and also to the severity of the cold and heat symptoms, the time of onset, duration, clinical manifestations, and accompanying symptoms. Common clinical cold and heat symptoms can be categorized into the following four situations:
1. Cold without Heat
In general, if the patient only feels cold without any sensation of heat, it is termed cold without heat. This can occur at the onset of an external pathogen before fever develops, or when cold pathogens invade the internal organs and meridians, as well as in cases of internal injury and deficiency. Depending on the characteristics of the patient’s cold sensation, it can be clinically referred to as aversion to wind, aversion to cold, chills, or fear of cold.
Aversion to Wind: This is when the patient feels shivering in the presence of wind and feels better when avoiding it. This is often caused by external wind pathogens. When the wind pathogen is on the surface and the defensive Qi is damaged, it loses its ability to warm the body, hence the patient feels cold when exposed to wind and feels better when avoiding it. Additionally, aversion to wind can also be seen in individuals with a deficiency of lung Qi.
Aversion to Cold: This is when the patient feels cold all the time, and even with added clothing or heating, the cold sensation does not alleviate. This is often seen at the onset of an external pathogen, where the defensive Qi cannot reach the surface, and the body loses its warmth, leading to aversion to cold. At this time, even with clothing or heat, the Yang Qi of the body cannot reach the surface, hence the cold sensation remains. This can be seen in various early stages of external diseases, and the nature of the disease is often substantial.
Chills: If the patient experiences chills accompanied by shivering, it is termed chills. The pathogenesis and nature of the disease are similar to aversion to cold.
It should be noted that in external diseases, the symptoms of aversion to wind, aversion to cold, and chills exist independently for a very short time, and soon fever symptoms will appear, becoming aversion to cold with fever or alternating cold and heat. There are also a few cases where these symptoms persist for a longer time, but fever will generally appear eventually. This is helpful for understanding the progression of the disease.
Fear of Cold: This is when the patient feels cold but can alleviate it by adding clothing or getting close to a fire. This is often due to internal cold conditions. The body has been injured for a long time, leading to internal Yang Qi deficiency, or excessive cold pathogens directly injuring the Yang Qi, resulting in the inability to warm the surface and the sensation of fear of cold.
At this time, if clothing is added or one gets close to a fire, it can prevent the consumption of Yang Qi, or using heat to assist Yang can temporarily restore Yang Qi, warming the surface and alleviating the fear of cold.
2. Heat without Cold
If the patient only feels fever without any sensation of cold, it is termed heat without cold. This can be seen in internal heat conditions, and depending on the severity, duration, and changes in the heat, it can be classified into strong heat, tidal heat, and mild heat.
Strong Heat: This is when the patient has a high fever (body temperature exceeds 39 degrees Celsius) that persists without subsiding, belonging to internal excess heat conditions. This is caused by wind-cold pathogens entering the interior and transforming into heat or warm heat pathogens transmitting to the interior, where the pathogenic factor is strong and the righteous Qi is real, leading to intense conflict, resulting in internal heat surging and reaching the exterior.
Tidal Heat: This is when the patient experiences fever at regular intervals, similar to tidal patterns. This can be seen in both external and internal diseases. Due to the varying intensity and duration of tidal heat, there are three clinical situations:
Yangming Tidal Heat: This type of tidal heat is often seen in the Yangming bowel excess conditions described in the “Treatise on Febrile Diseases,” hence termed Yangming tidal heat. Its characteristics include higher heat intensity, incomplete resolution of heat, and often exacerbation of heat intensity in the afternoon, hence also called afternoon tidal heat. This is due to pathogenic heat accumulating in the stomach and intestines, leading to dryness and constipation, with the disease located in the Yangming stomach and large intestine.
Wet-Heat Tidal Heat: This type of tidal heat is often seen in “warm diseases” involving damp-heat, hence termed wet-heat tidal heat. Its characteristics are that the patient feels very hot, but upon touching the skin, it may not feel very hot initially, and only after prolonged contact does it feel hot. Clinically, this is also referred to as “body heat not rising,” often occurring in the afternoon with intensified heat, and after resolution, heat remains. This is a unique heat type of damp-heat diseases, also belonging to the category of tidal heat.
Yin Deficiency Tidal Heat: This type of tidal heat is often seen in Yin deficiency conditions. Its characteristics include increased fever in the afternoon or at night, lower heat intensity, often only felt by the patient, and body temperature may not be high, often accompanied by feelings of heat in the chest, palms, and soles, hence also called “five hearts heat.” In severe cases, there is a sensation of heat emanating from the bone marrow, termed “bone steaming tidal heat.” This is due to various reasons leading to a deficiency of Yin fluids, with deficient Yang being hyperactive, resulting in internal heat.
Mild Heat: This is when the patient has a prolonged mild fever, with body temperature generally not exceeding 38 degrees Celsius, also known as long-term low fever. This can be seen in the later stages of warm diseases, internal injury due to Qi deficiency, Yin deficiency, and summer heat in children. In the later stages of warm diseases, residual pathogens remain, and residual heat lingers, leading to persistent mild fever.
Long-term mild fever caused by Qi deficiency is also termed Qi deficiency fever. Its characteristics include persistent low fever, which becomes significantly worse after exertion. The main pathogenesis is due to spleen Qi deficiency, insufficient middle Qi, and the inability to raise and distribute Yang Qi, leading to heat stagnation at the surface. Exertion consumes Qi, further depleting middle Qi, and Yang Qi cannot be distributed, hence the heat intensifies.
Summer Heat in Children: This refers to children experiencing persistent fever during hot weather, which resolves naturally when autumn cools down, also classified as mild heat. This is due to insufficient Qi and Yin in children (their temperature regulation mechanism is not yet fully developed), leading to an inability to adapt to the hot summer climate.
3. Aversion to Cold with Fever
When aversion to cold and fever sensations coexist, it is termed aversion to cold with fever. This is one of the main symptoms of external pathogenic conditions.
The pathological changes associated with aversion to cold with fever symptoms are a response to the initial onset of external pathogenic conditions, where the external pathogen contends with the defensive Yang Qi. The external pathogen binds the surface, obstructing the defensive Yang, leading to aversion to cold due to loss of warmth at the surface. The defensive Yang fails to disperse, leading to fever. If cold pathogens are felt, it can lead to a stronger binding of the surface and significant aversion to cold; if heat pathogens are felt, it assists Yang, leading to significant fever symptoms.
Inquiring about the severity of cold and heat can often help infer the nature of the external pathogen. For example, if aversion to cold is severe and fever is mild, it often indicates an external wind-cold condition. If fever is severe and aversion to cold is mild, it often indicates an external wind-heat condition. If aversion to cold and fever are present along with aversion to wind, spontaneous sweating, and a floating pulse, it often indicates an external pathogenic deficiency condition. If aversion to cold and fever are present with headache, body aches, no sweating, and a floating tight pulse, it indicates an external pathogenic excess condition. Sometimes, based on the severity of cold and heat, one can also infer the balance of pathogenic and righteous Qi. Generally speaking, if the pathogen is light and the righteous Qi is strong, both aversion to cold and fever are mild; if the pathogen is strong and the righteous Qi is real, both aversion to cold and fever are severe; if the pathogen is strong and the righteous Qi is weak, aversion to cold is severe and fever is mild.
4. Alternating Cold and Heat
When the patient experiences alternating episodes of aversion to cold and fever, where they feel cold during cold episodes and heat during heat episodes, it is termed alternating cold and heat. The boundaries are clear, occurring once a day or several times a day, and can be seen in lesser Yang disease, warm diseases, and malaria.
When external pathogens invade the body, during the process of moving from the surface to the interior, the pathogenic Qi lingers between the surface and the interior, unable to fully enter the interior, while the righteous Qi cannot expel the pathogen. At this time, the pathogenic Qi is not too strong, and the righteous Qi has not weakened, leading to a stalemate between the righteous and the pathogenic. If the righteous Qi prevails, it results in heat; if the pathogenic Qi prevails, it results in cold, leading to alternating cold and heat.
(2) Ask about Sweating
Sweat is the transformation of body fluids, and within the body, it is body fluid that evaporates through Yang Qi from the pores to the surface, resulting in sweat.
Normal individuals can sweat under conditions of overexertion, intense exercise, hot environments, or emotional stress, which is a normal phenomenon. When disease occurs, various factors can affect the generation and regulation of sweat, leading to abnormal sweating. During illness, sweating has a dual nature; on one hand, sweating can expel pathogenic factors and promote recovery, which is a normal response of the body against pathogens. On the other hand, sweat is generated from body fluids, and excessive sweating can deplete body fluids, leading to severe consequences of Yin and Yang imbalance. When inquiring about sweating, it is important to ask the patient whether they sweat, the timing of sweating, the location, the amount of sweat, the characteristics of sweating, accompanying symptoms, and changes in symptoms after sweating. Common situations include:
1. No Sweating
Both external and internal injuries, whether new or chronic diseases, can present with a complete absence of sweating. In external diseases, the pathogen obstructs the surface, preventing Qi from dispersing, hence no sweating occurs. This indicates a dysfunction of the regulating function of the defensive Qi. When the pathogenic Qi enters the interior and depletes the Ying Yin, there is also no sweating, indicating a deficiency of body fluids and an obstruction in sweat generation. In cases of long-standing internal injury, the absence of sweating can be complex, possibly due to lung Qi failing to disperse, leading to a dysfunction in sweat regulation; it may also be due to insufficient blood and depleted body fluids, leading to a loss of the source of sweat generation, hence no sweating.
2. Sweating
Pathological sweating can occur in various situations. Whenever the Ying and Wei are not in harmony, internal heat is excessive, or Yin and Yang are imbalanced, it can lead to abnormal sweating. Inquiring about the timing and amount of sweating, as well as the duration of the illness, can often help determine whether the disease is at the surface or interior, the state of Yin and Yang, and the prognosis.
For example, if the patient sweats, has a short illness, and presents with fever and aversion to wind, it indicates a surface deficiency condition due to external wind pathogens. If the patient has profuse sweating, accompanied by steaming heat, flushed face, and thirst for cold drinks, it indicates an excess heat condition. This is due to internal heat being excessive, leading to profuse sweating. At this time, the pathogenic Qi is still strong, and the righteous Qi is not deficient, leading to a struggle between the righteous and the pathogenic, resulting in continuous sweating. The more the sweat, the more the righteous Qi is harmed.
If the patient has cold sweat dripping or sweating like oil, accompanied by shortness of breath, pale complexion, cold extremities, and a weak pulse, this sweating is often termed “loss of sweat” or “absolute sweat.” This is due to severe illness, significant depletion of righteous Qi, and loss of Yang Qi, leading to a significant loss of body fluids, indicating a poor prognosis.
Frequent sweating during the day, especially after activity, is termed spontaneous sweating. This is often accompanied by fatigue, shortness of breath, or cold extremities, and is often due to Yang deficiency or Qi deficiency, which fails to protect the surface, leading to loose pores and loss of body fluids. After activity, Yang Qi disperses outward, leading to further Qi deficiency, hence increased sweating. Therefore, spontaneous sweating is often seen in Qi deficiency or Yang deficiency conditions.
Night sweats occur when the patient sweats while sleeping, and the sweating stops upon waking, termed night sweats. This is often accompanied by tidal heat, flushed cheeks, five hearts heat, red tongue, and thin rapid pulse, indicating Yin deficiency. Yin deficiency leads to internal heat, and during sleep, the defensive Yang enters the interior, leading to loose pores and internal heat evaporating body fluids, hence night sweats occur. Upon waking, the defensive Yang returns to the surface, and the pores close, hence sweating stops.
If the patient first experiences aversion to cold and shivering, with a painful expression, tossing and turning, followed by sweating, it is termed “battle sweat.” This is often seen during the process of external heat disease, when the struggle between the pathogenic and the righteous is intense, marking a turning point in the disease. Battle sweat is a manifestation of the struggle between the pathogenic and the righteous, often indicating a strong pathogenic presence and weak righteous Qi. Once Yang Qi recovers, the struggle between the pathogenic and the righteous can lead to battle sweat. The outcome of battle sweat can be one of two scenarios: either sweating occurs and the disease resolves, with a calm pulse and cool body, thirst alleviated, indicating that the righteous Qi has triumphed over the pathogenic Qi, and the disease is gradually recovering, which is a good sign; or after battle sweat, the fever does not subside, with symptoms of restlessness and a rapid pulse, indicating that the righteous Qi is weak and cannot overcome the pathogenic Qi, leading to internal heat and worsening of the disease, which is a critical sign.
3. Localized Sweating
Head Sweating: This refers to excessive sweating only on the head or neck, also known as “only head sweating.” This can be due to upper jiao heat or middle jiao damp-heat rising, forcing body fluids to the surface; or it can be due to critical illness with floating Yang.
Half-Body Sweating: This refers to sweating on one side of the body or the absence of sweating on one side, either upper or lower, left or right. This can be seen in pre-stroke, stroke conditions, atrophy, or paralysis. This is often due to obstruction of the meridians on the affected side, leading to unbalanced Qi and blood flow.
Hand and Foot Sweating: This refers to excessive sweating in the palms and soles. This is often due to internal heat stagnation or Yin deficiency with Yang excess, forcing body fluids to the extremities.
(3) Ask about the Whole Body
Asking about the whole body involves inquiring whether the patient has any pain or other discomfort throughout the body. Clinically, this can be done in order from head to toe.
1. Ask about Pain
Pain is a common subjective symptom seen in various medical specialties. During the inquiry, it is important to clarify the cause, nature, location, timing, and preferences regarding the pain.
(1) Causes of Pain: There are many causes of pain, including external pathogens and internal injuries, with pathogenesis being either deficiency or excess. Pain due to obstruction is classified as excess, while pain due to lack of nourishment is classified as deficiency.
(2) Nature of Pain: Due to the different causes and pathogenesis of pain, the nature of the pain can also vary, and clinically, the following categories can be observed:
① Distending Pain: Pain accompanied by a feeling of distension is termed distending pain. This can occur in various parts of the body, but is more common in the chest, hypochondrium, stomach, and abdomen. This is often due to Qi stagnation.
② Stabbing Pain: Pain that feels like being pricked by a needle is termed stabbing pain. Its characteristic is that the area of pain is relatively small and fixed. This is often due to blood stasis. Stabbing pain can occur in various parts of the body, but is most common in the chest, hypochondrium, stomach, and lower abdomen.
③ Cramping Pain: Pain that is severe and feels like being cut or twisted is termed cramping pain. Its characteristic is that the pain is unbearable and feels like cutting or twisting. This is often due to sudden obstruction of the meridians by tangible excess pathogens or internal cold invasion, leading to Qi stagnation and blood flow obstruction.
This can be seen in heart pain due to blood stasis, or abdominal pain caused by ascariasis or internal cold invasion.
④ Wandering Pain: Pain that moves around or shifts is termed wandering pain. Its characteristic is that the pain is not fixed, or the patient cannot pinpoint the exact location of the pain. This is often due to wind pathogens lingering in the body’s meridians and joints, obstructing Qi flow. Qi is formless and prefers to flow freely; stagnation of Qi leads to pain, which is often seen in wandering pain. This can be seen in wind-damp bi syndrome or Qi stagnation.
⑤ Pulling Pain: Pain that has a pulling sensation or radiates to other areas is termed pulling pain. Its characteristic is that the pain often appears in a strip or radiating pattern, or has a starting and stopping point, with a pulling sensation. This is often due to insufficient nourishment of the tendons or obstruction of the meridians. This can be seen in chest obstruction, liver Yin deficiency, or liver channel excess heat.
⑥ Burning Pain: Pain that feels like burning is termed burning pain. Its characteristic is that the painful area feels hot, as if the disease is superficial, and sometimes the painful area can also be felt to be hot upon touch, often preferring coolness. This is often due to fire heat pathogens invading the meridians or Yin deficiency with Yang excess, leading to internal heat.
⑦ Cold Pain: Pain that feels cold is termed cold pain. Its characteristic is that the painful area feels cool, as if the disease is superficial, and sometimes it feels cool to the touch, often preferring warmth. This is often due to cold congealing the tendons or insufficient Yang Qi.
⑧ Heavy Pain: Pain accompanied by a feeling of heaviness is termed heavy pain. This is often seen in the head, limbs, and lower back. This is often due to damp pathogens obstructing Qi flow, commonly seen in damp conditions.
⑨ Empty Pain: Pain that feels empty is termed empty pain. Its characteristic is that the pain feels light and empty, often preferring warmth and pressure. This is often due to insufficient essence and blood. This can be seen in Yang deficiency, Yin deficiency, blood deficiency, or both Yin and Yang deficiency.
⑩ Dull Pain: Pain that is subtle and persistent is termed dull pain. Its characteristic is that the pain is relatively mild and tolerable, lingering for a long time. This is often due to insufficient Qi and blood, or weak Yang Qi, leading to stagnation of Qi and blood flow.
(3) Location of Pain: Inquiring about the location of pain can help determine the location of the disease and the corresponding changes in the meridians and organs.
① Headache: Pain in the entire head or in the front, back, or sides of the head is referred to as headache. Both external pathogens and internal injuries can cause headaches. External pathogens are often due to invasion of the brain by pathogens, leading to obstruction of the meridians, which is classified as excess. Internal injuries are often due to weakness of the organs, failure of clear Yang to rise, or insufficient kidney essence, leading to insufficient nourishment of the brain, which is classified as deficiency. Pathological products from organ dysfunction, such as phlegm and blood stasis obstructing the meridians, can lead to headaches, which can be either deficiency or excess, or a mixture of both. Severe headaches with continuous pain and accompanying external symptoms indicate an external headache. For example, a heavy head with heavy limbs indicates wind-damp headache. Mild headaches with a long duration that come and go often indicate internal injury headaches. For example, a dull headache that worsens with overexertion indicates Qi deficiency headache. A dull headache with dizziness and pale complexion indicates blood deficiency headache. A feeling of emptiness in the head, with soreness in the lower back and knees, indicates kidney deficiency headache. A headache with dizziness and spontaneous sweating indicates spleen deficiency headache. Severe stabbing pain in the head, with a fixed location, indicates blood stasis headache. A headache that feels wrapped, with nausea and dizziness, indicates phlegm turbidity headache. A headache that feels swollen, with bitter mouth and dry throat, indicates liver fire headache.
Headaches accompanied by nausea, vomiting, fullness in the chest, and loss of appetite indicate food accumulation headache.
Pain in different parts of the head is generally related to the distribution of the meridians, such as pain in the head and neck indicating Taiyang meridian disease, pain in the forehead indicating Yangming meridian disease, pain in the sides of the head indicating Shaoyang meridian disease, pain on the top of the head indicating Jueyin meridian disease, and pain radiating to the teeth indicating Shaoyin meridian disease.
② Chest Pain: This refers to self-reported pain in the center or sides of the chest. The chest is located in the upper jiao, housing the heart and lungs, so chest diseases are often related to heart and lung changes. Chest pain is often caused by obstruction of Qi flow in the chest. Chest pain, tidal heat, night sweats, and coughing up blood indicate lung Yin deficiency, due to deficiency fire injuring the lung collaterals. Chest pain with a feeling of tightness, radiating to the shoulder and arm, indicates chest obstruction, often due to poor circulation of Qi and blood in the heart vessels. This can be seen in conditions of insufficient Yang, phlegm turbidity obstructing the heart, or Qi deficiency and blood stasis. Severe chest pain with cyanosis of the face and extremities indicates true heart pain, caused by sudden blockage of the heart vessels. Chest pain with strong heat and flushed face, accompanied by shortness of breath and rapid breathing, indicates heat pathogens obstructing the lungs, leading to loss of the lung’s ability to disperse and descend.
Chest pain, tidal heat, night sweats, and coughing up blood indicate lung Yin deficiency, due to deficiency fire injuring the lung collaterals. Chest pain with fullness, wandering pain, and easy irritability indicates liver Qi stagnation, due to emotional distress leading to obstruction of Qi flow in the chest.
③ Hypochondriac Pain: This refers to pain on one or both sides of the hypochondrium. The hypochondrium is associated with the liver and gallbladder, and the meridians of the liver and gallbladder run through this area. Therefore, hypochondriac pain is often related to liver and gallbladder conditions.
Hypochondriac distension and pain, with easy irritability, are often due to liver Qi stagnation. Burning pain in the hypochondrium is often due to liver fire stagnation. Hypochondriac distension and pain, with yellowing of the skin and eyes, are often due to damp-heat accumulation in the liver and gallbladder, which can be seen in jaundice. Fixed stabbing pain in the hypochondrium is due to blood stasis obstructing the meridians. Hypochondriac pain with fullness on the affected side, with pain upon coughing or spitting, is due to fluid retention in the chest and hypochondrium, which can be seen in pleural effusion.
④ Stomach Pain: The stomach area includes the entire stomach body. The upper opening of the stomach is called the upper jiao, and the lower opening is called the lower jiao, with the stomach body located between the two. Stomach pain refers to pain in the stomach area. Various causes such as cold, heat, food accumulation, and Qi stagnation, as well as dysfunction of the stomach and spleen, can all affect the smooth flow of Qi in the stomach, leading to pain symptoms.
The nature of stomach pain varies depending on the cause. For example, cold stomach pain is often severe and alleviated by warmth, indicating cold pathogens invading the stomach. Burning stomach pain, with a preference for food and bad breath, indicates excessive stomach fire. Distension and pain in the stomach, with discomfort after belching, indicate Qi stagnation in the stomach, often due to liver Qi invading the stomach; stabbing pain in the stomach, with a fixed location, indicates blood stasis in the stomach; distension and pain in the stomach, with sour belching and loss of appetite, indicate food stagnation in the stomach; dull stomach pain, with vomiting clear fluids, indicates stomach Yang deficiency; burning stomach pain with noisy stomach, with no desire to eat, indicates stomach Yin deficiency.
⑤ Abdominal Pain: The abdominal area is quite broad and can be divided into upper abdomen, lower abdomen, and lower abdomen. The area around the navel is called the umbilical area, associated with the spleen and small intestine. The area above the navel is called the upper abdomen, associated with the spleen, stomach, and liver and gallbladder. The area below the navel is called the lower abdomen, associated with the bladder, uterus, and large and small intestines. The lower sides of the abdomen are called the lower abdomen, where the liver meridian runs.
Based on the location of the pain, one can infer the affected organ. Based on the nature of the pain, one can determine the cause and nature of the disease. For example, dull pain in the upper abdomen, with loose stools, preferring warmth and pressure, indicates spleen and stomach deficiency and cold. Distension and pain in the lower abdomen, with difficulty urinating, often indicates bladder obstruction. Stabbing pain in the lower abdomen, with difficulty urinating, indicates blood accumulation in the bladder. Cold pain in the lower abdomen, radiating to the genital area, indicates cold congealing in the liver meridian. Pain around the navel, with a mass that can be moved upon palpation, indicates intestinal obstruction due to worms. Severe, sudden, and intense abdominal pain, with distension and refusal to palpate, often indicates excess conditions.
In contrast, dull, lingering, and tolerable abdominal pain, with a preference for pressure and alleviation after eating, often indicates deficiency conditions. Abdominal pain that is alleviated by warmth often indicates cold conditions. Abdominal pain that is worsened by cold often indicates heat conditions.
6. Low Back Pain: The nature of the pain can help determine the cause. For example, cold pain in the lower back, primarily in the spine, with limited movement, often indicates cold-damp obstruction. Cold pain in the lower back, with clear and prolonged urination, indicates kidney deficiency. Fixed stabbing pain in the lower back indicates bruising or trauma.
Based on the location of the pain, one can infer where the pathogen is located. For example, pain in the spine often indicates bone disease; pain primarily on both sides of the lower back often indicates kidney disease; pain in the lower back radiating to the lower limbs often indicates lower limb meridian disease. Pain in the lower back radiating to the abdomen, with a band-like sensation, often indicates disease in the belt meridian.
7. Back Pain: The location and nature of the pain can help determine the location and cause of the disease. For example, back pain radiating to the head and neck, accompanied by external symptoms, indicates wind-cold invasion of the Taiyang meridian; cold pain in the back, with aversion to cold and cold extremities, indicates Yang deficiency; empty pain in the spine, with difficulty bending and straightening, often indicates deficiency of essence and Qi, with damage to the governing vessel.
8. Limb Pain: Limb pain is often caused by wind, cold, and damp pathogens invading the meridians, muscles, and joints, obstructing the flow of Qi and blood. It can also be due to spleen or kidney deficiency. Based on the location and nature of the pain, one can determine the cause and location of the disease. For example, joint pain in the limbs, with wandering pain, often indicates wind bi syndrome; joint pain in the limbs, with a feeling of heaviness throughout the body, often indicates warm bi syndrome; severe joint pain in the limbs, alleviated by warmth, often indicates cold bi syndrome; burning pain in the limbs, with redness and swelling, often indicates heat bi syndrome; dull pain in the heel or knee often indicates kidney Qi deficiency.
③ Whole Body Pain: Whole body pain refers to pain felt in the limbs, lower back, and other areas. Based on the nature and duration of the pain, one can determine whether it is due to external pathogens or internal injuries. For example, new whole body pain, with soreness and heaviness, often accompanied by external symptoms, indicates external pathogens binding the surface; if the pain persists in a long-term bedridden patient, it indicates Qi and blood deficiency, leading to obstruction of the meridians.
2. Ask about Other Discomforts
Asking about other discomforts throughout the body involves inquiring about symptoms in various areas, such as the head, chest, abdomen, etc., excluding pain. Common other discomfort symptoms include dizziness, lightheadedness, dry eyes, vision loss, tinnitus, hearing loss, chest tightness, palpitations, abdominal distension, numbness, etc. During clinical inquiries, it is important to ask about any other discomfort symptoms, their obvious triggers, duration, characteristics, and accompanying symptoms.
(1) Dizziness: This refers to the patient’s subjective feeling of blurred vision and rotation. In mild cases, closing the eyes can alleviate the feeling; in severe cases, the patient feels as if the world is spinning and cannot stand, and closing the eyes does not help. This can be caused by external pathogens invading or dysfunction of the organs leading to obstruction of the meridians, preventing the clear Yang from rising, or wind and fire disturbing the body, leading to obstruction of the brain or insufficient nourishment of the brain, resulting in dizziness. Common clinical causes of dizziness include wind and fire disturbance, Yin deficiency with Yang excess, heart and spleen blood deficiency, insufficient middle Qi, kidney essence deficiency, and phlegm turbidity obstructing the brain.
(2) Eye Pain, Dizziness, Dry Eyes, Night Blindness
① Eye Pain: Pain and redness in the eyes indicate liver fire; red, swollen, and painful eyes, with sensitivity to light and excessive tearing, often indicate wind-heat; severe eye pain, accompanied by headache, nausea, vomiting, and dilated pupils, often indicates glaucoma; intermittent dull eye pain often indicates Yin deficiency with excessive fire.
② Dizziness: This refers to the subjective feeling of blurred vision or seeing black spots or flashes. This is often due to liver and kidney Yin deficiency, liver Yang excess, insufficient liver blood, or Qi and blood deficiency, leading to insufficient nourishment of the eyes.
③ Dry Eyes: This refers to a feeling of dryness or foreign body sensation in the eyes. Accompanied by redness and tearing, this often indicates liver fire; if it worsens over time and improves with rest, it often indicates blood deficiency and Yin deficiency.
④ Night Blindness: This refers to difficulty seeing in dim light, with normal vision during the day, often due to liver blood deficiency or kidney Yin deficiency, leading to insufficient nourishment of the eyes.
(3) Tinnitus, Hearing Loss, Reduced Hearing
① Tinnitus: This refers to the subjective feeling of ringing in the ears, such as the sound of cicadas or waves, which can occur in one or both ears, intermittently or continuously. Clinically, there is a distinction between deficiency and excess; if the ringing is sudden and loud, and pressing on the ear does not alleviate it, it indicates excess, often due to excessive liver and gallbladder fire; if the ringing is gradual and soft, and pressing on the ear alleviates it, it indicates deficiency, often due to kidney deficiency and insufficient essence, leading to insufficient nourishment of the ears.
② Hearing Loss: This refers to the loss of hearing ability, often developing from tinnitus. Sudden hearing loss is often due to excess, caused by obstruction of the clear orifices by pathogens; gradual hearing loss is often due to deficiency, often due to damage to the organs. Generally, deficiency is more common than excess, and excess is easier to treat while deficiency is more difficult.
③ Reduced Hearing: This refers to unclear hearing, often leading to misperceptions, indicating a reduction in hearing ability. This is often due to kidney deficiency or invasion of wind pathogens.
(4) Chest Tightness: This refers to a feeling of blockage or fullness in the chest, often due to obstruction of Qi flow in the chest. Due to the many causes of chest tightness, this symptom can appear in various diseases.
(5) Palpitations: Under normal conditions, the patient feels abnormal heartbeats, anxiety, and inability to control them, termed palpitations. If the palpitations are due to fright, they are termed fright palpitations. Palpitations are often spontaneous, while fright palpitations are often due to fright. “Startled palpitations” is a further development of palpitations, where the heart feels more intense and lasts longer, indicating a more severe condition. There are many causes of palpitations, mainly due to disturbances of the heart spirit. For example, deficiency of heart Yang, leading to insufficient heart Qi; Qi and blood deficiency, leading to insufficient nourishment of the heart; Yin deficiency with excessive fire, disturbing the heart spirit; water retention, leading to obstruction of the heart; phlegm turbidity obstructing the heart Qi; Qi stagnation and blood stasis disturbing the heart spirit can all lead to palpitations, fright palpitations, or startled palpitations.
(6) Abdominal Distension: This refers to a feeling of fullness and distension in the abdomen, as if something is pressing against it, or an increase in abdominal size. There are many causes of abdominal distension, with symptoms being either deficiency or excess, cold or heat. The main pathogenesis is often due to obstruction of Qi flow; deficiency leads to Qi stagnation, while excess leads to Qi stagnation. Excess conditions can be seen in cold-damp invading the stomach, Yangming bowel excess, food accumulation in the intestines, liver Qi stagnation, and phlegm retention. Deficiency conditions are often seen in spleen deficiency. The abdominal area is quite broad, and different areas of distension indicate different diseases. For example, distension in the upper abdomen often indicates spleen and stomach disease, while distension in the lower abdomen often indicates bladder disease, and distension in the lower sides often indicates liver and gallbladder disease.
(7) Numbness: This refers to a reduction or loss of sensation. This is often seen in the head, face, and limbs. It can be caused by Qi and blood deficiency or obstruction of the meridians by wind, phlegm, and dampness, leading to stagnation of Qi and blood. The main pathogenesis is due to the meridians losing nourishment from Qi and blood.
(4) Ask about Diet and Taste
Asking about diet and taste includes inquiring about thirst, drinking, eating, and taste preferences. Attention should be paid to whether there is thirst, how much water is consumed, preferences for hot or cold foods, appetite, amount of food consumed, the nature of food, and any abnormal tastes or odors in the mouth.
1. Ask about Thirst and Drinking
Inquiring about the patient’s thirst and drinking can help understand the state of body fluids and their distribution, as well as the nature of the disease’s cold, heat, deficiency, or excess.
(1) No Thirst: This indicates that body fluids are not harmed, seen in cold conditions or without obvious heat pathogens.
(2) Thirst: Thirst is generally caused by insufficient body fluids or obstruction in their distribution. Clinically, the following situations can be observed:
① Excessive Thirst: This refers to significant thirst, with a large amount of drinking, indicating severe depletion of body fluids. This is often seen in excess heat conditions, diabetes, and after sweating, vomiting, or diarrhea.
② Mild Thirst: This refers to the patient feeling dry or thirsty but not wanting to drink much. This indicates mild damage to body fluids or obstruction in their distribution. This can be seen in Yin deficiency, damp-heat, phlegm retention, or blood stasis.
In clinical practice, the differentiation of thirst and drinking should be based on the characteristics of thirst, the amount of drinking, and related accompanying symptoms.
2. Ask about Appetite and Food Intake
Inquiring about the patient’s appetite and food intake can help assess the strength of the spleen and stomach function, the severity of the disease, and the prognosis.
(1) Reduced Appetite and Aversion to Food: Reduced appetite, also known as “poor appetite” or “little intake,” refers to the patient not wanting to eat. Aversion to food, also known as food aversion, refers to a dislike of food. Lack of appetite and aversion to food generally fall into two categories: one is not feeling hungry and not wanting to eat, and the other is feeling hungry but not wanting to eat or disliking food. Both conditions are due to disharmony of the spleen and stomach and weakened digestive and absorption functions.
① Reduced Appetite: The patient does not want to eat, and the amount of food consumed decreases, often seen in spleen and stomach Qi deficiency, dampness obstructing the spleen, etc.
② Aversion to Food: This is often due to food injury. If a woman experiences aversion to food and vomiting in early pregnancy, it is termed morning sickness.
③ Hunger without Desire to Eat: This refers to the patient feeling hungry but not wanting to eat or eating very little, also falling under the category of reduced appetite. This can be seen in stomach Yin deficiency.
(2) Increased Appetite and Easy Hunger: This refers to increased appetite, with a large amount of food consumed, feeling hungry shortly after eating, also known as “eating a lot and feeling hungry.” Clinically, this is often accompanied by gradual weight loss. This can be seen in excessive stomach fire, strong stomach function with weak spleen function, etc. It can also be seen in diabetes.
This is generally due to excessive digestion of the stomach.
(3) Food Cravings: This refers to a strong desire for certain foods or unusual substances. Cravings for unusual substances are also known as pica; if children crave unusual substances like dirt or raw rice, it often indicates worm accumulation. If a married woman experiences cravings for sour foods after menstruation, it often indicates pregnancy.
When inquiring about appetite and food intake, attention should also be paid to how the patient eats. For example, if the patient prefers hot foods, it often indicates cold conditions; if they prefer cold foods, it often indicates heat conditions. If eating provides temporary relief, it often indicates deficiency conditions; if eating worsens symptoms, it often indicates excess conditions or a mixture of deficiency and excess. During the course of the disease, if appetite gradually recovers, it indicates that the stomach Qi is gradually recovering, which is a good prognosis; conversely, if appetite gradually declines and food intake decreases, it indicates that the stomach Qi is gradually weakening, which is often a poor prognosis. If the patient cannot eat due to severe illness, suddenly overeats, or consumes a large amount, it indicates a critical situation of impending death, termed “returning light.” This is essentially a sign of failing middle Qi, indicating a pre-death state.
3. Taste
Taste refers to abnormal sensations in the mouth. A bland taste often indicates spleen and stomach Qi deficiency. A sweet taste is often seen in spleen and stomach damp-heat conditions. A sticky taste often indicates dampness obstructing the spleen and stomach. A sour taste in the mouth can be seen in liver and gallbladder heat conditions. A rotten sour taste is often seen in food injury conditions.
A bitter taste indicates heat conditions, often seen in fire pathogens and liver and gallbladder heat conditions. A salty taste often indicates kidney disease and cold conditions.
(5) Ask about Urination and Defecation
Asking about urination and defecation involves inquiring about the characteristics, color, odor, quantity, timing, and sensations associated with urination and defecation. Inquiring about these can help assess the strength of the body’s digestive function, the state of body fluid metabolism, and is also an important basis for differentiating the nature of the disease’s cold, heat, deficiency, or excess.
Regarding the characteristics, color, and odor of urination and defecation, these have been discussed in the sections on observation and olfaction. Here, we will introduce the frequency, quantity, sensations during defecation, and timing.
1. Ask about Defecation
Healthy individuals typically have one or two bowel movements per day, with yellow, formed, soft stools that pass smoothly. If affected by disease, the digestive function may be impaired, leading to mucus or undigested food in the stool. Imbalances in Qi, blood, and body fluids, as well as dysfunction of the organs, can lead to abnormalities in the frequency and sensations of defecation.
(1) Abnormal Frequency: Abnormal frequency refers to an increase or decrease in the number of bowel movements beyond the normal range, with constipation and diarrhea being the two categories.
① Constipation: This refers to hard stools. It indicates that feces have been retained in the intestines for too long, with prolonged intervals between bowel movements, typically more than four to seven days, termed constipation. The pathogenesis is generally due to dysfunction of the large intestine’s ability to transport. This can be seen in conditions of heat accumulation in the intestines, Qi stagnation, Qi and blood deficiency, or cold congealing.
② Diarrhea: Also known as loose stools or diarrhea, this refers to soft, unformed stools, which may even be watery, with shortened intervals between bowel movements, often exceeding three to four times a day. This is generally due to dysfunction of the spleen and stomach, water retention in the intestines, or excessive transport by the large intestine. This can be seen in spleen deficiency, kidney Yang deficiency, liver Qi invading the spleen, food injury, damp-heat accumulation in the large intestine, or external pathogen invasion.
(2) Abnormal Sensations during Defecation: Abnormal sensations during defecation refer to noticeable discomfort during bowel movements, with different causes leading to different sensations.
① Burning Sensation: This refers to a burning sensation in the anus during defecation. The pathogenesis is due to damp-heat accumulation in the large intestine. This can be seen in damp-heat diarrhea or summer-heat diarrhea.
② Incomplete Defecation: This refers to abdominal pain with a feeling of incomplete defecation, often due to obstruction of Qi flow in the intestines. This can be seen in liver Qi invading the spleen, food injury leading to diarrhea, or damp-heat accumulation.
③ Urgency and Heaviness: This refers to abdominal pain and a constant urge to defecate, with a feeling of heaviness in the anus, often due to damp-heat obstructing the intestines. This is a common symptom in dysentery.
④ Incontinence: This refers to persistent diarrhea, where the patient cannot control bowel movements, often due to prolonged illness leading to deficiency, or weakness of the spleen and kidney Yang, leading to loss of control. This can be seen in spleen Yang deficiency or kidney Yang deficiency.
⑤ Prolapse: This refers to a feeling of heaviness in the anus, with a sensation of the anus wanting to protrude. This is often due to deficiency of spleen Qi, leading to descent of the middle Qi. This is often seen in conditions of middle Qi descent.
2. Ask about Urination
Under normal circumstances, healthy individuals have a daily urine output of about 1000 to 1800 milliliters, with daytime urination occurring 3-5 times and nighttime urination occurring 0-1 time. The frequency and volume of urination can vary slightly due to factors such as fluid intake, temperature, sweating, and age. If affected by disease, if the body’s fluids and blood are insufficient, or if the Qi transformation function is impaired, or if water retention occurs, it can lead to abnormalities in urination frequency, volume, and sensations during urination.
(1) Abnormal Urine Volume: Abnormal urine volume refers to excessive or insufficient urine output beyond the normal range.
① Increased Urine Volume: This is often due to cold congealing Qi flow, leading to water not being transformed, or kidney Yang deficiency, leading to insufficient Qi transformation, resulting in increased urine output. This can be seen in deficiency cold conditions, kidney Yang deficiency, and diabetes.
② Decreased Urine Volume: This can be due to insufficient body fluids, insufficient urine production, or urinary tract obstruction, or Yang Qi deficiency, leading to impaired Qi transformation, causing water to overflow into the skin. This can be seen in excess heat conditions, sweating, vomiting, water retention, and urinary retention.
(2) Abnormal Urination Frequency:
① Increased Urination Frequency: Also known as frequent urination, this is due to dysfunction of the bladder’s Qi transformation. This can be seen in lower jiao damp-heat, lower jiao deficiency cold, or kidney Qi instability.
② Decreased Urination Frequency: This can be seen in urinary retention, as described in the urinary abnormalities section.
(3) Abnormal Urination: This refers to changes in the sensations and processes of urination, leading to abnormal situations such as painful urination, urinary retention, incontinence, nocturnal enuresis, or urinary obstruction.
① Painful Urination: This refers to difficulty urinating, accompanied by a burning sensation. This is often due to damp-heat entering the bladder, burning the meridians, and obstructing Qi flow. This can be seen in urinary tract infections.
② Urinary Retention: This refers to difficulty urinating, with dribbling urination. This can be classified as urinary retention, with dribbling being a common symptom. The pathogenesis can be either deficiency or excess. Excess is often due to damp-heat accumulation, liver Qi stagnation, or blood stasis, while deficiency is often due to aging and Qi deficiency, leading to impaired bladder function.
③ Post-Urination Dribbling: This refers to dribbling after urination. This is often due to kidney Qi instability.
④ Incontinence: This refers to the inability to control urination, leading to involuntary leakage. This is often due to insufficient kidney Qi, leading to instability in the lower jiao; or deficiency cold in the lower jiao, leading to inability to warm the bladder. If the patient is unconscious and urinates involuntarily, it indicates a severe condition.
⑤ Nocturnal Enuresis: This refers to involuntary urination during sleep, commonly known as bedwetting. This is often seen in children. The basic pathogenesis is due to the bladder’s inability to restrain. This can be seen in kidney Yin deficiency, kidney Yang deficiency, or spleen Qi sinking.
(6) Ask about Sleep
Sleep is related to the circulation of the body’s defensive Qi and the balance of Yin and Yang. Under normal circumstances, the defensive Qi circulates in the Yang meridians during the day, and when Yang Qi is abundant, the person is awake; at night, it circulates in the Yin meridians, and when Yin Qi is abundant, the person sleeps. When inquiring about sleep, it is important to understand whether the patient has insomnia or excessive sleepiness, the duration of sleep, difficulty falling asleep, whether they dream, etc. Common sleep disorders include insomnia and excessive sleepiness.
1. Insomnia: Insomnia, also known as “sleeplessness” or “inability to sleep,” refers to difficulty falling asleep, waking easily, difficulty returning to sleep, or restless sleep, or even total sleeplessness. The pathogenesis is often due to Yang failing to enter Yin, leading to the spirit being unsettled. Insufficient Qi and blood can lead to the spirit being un-nourished; Yin deficiency with Yang excess can lead to internal heat; insufficient kidney water and excessive heart fire can disturb the heart spirit, leading to insomnia, which can also occur due to phlegm-heat, food accumulation, or blood stasis disturbing the heart spirit, leading to insomnia, which is classified as an excess condition. This can be seen in heart and spleen deficiency, heart and kidney disharmony, liver Yang excess, phlegm-heat disturbing the heart, or food stagnation in the stomach.
2. Excessive Sleepiness: Excessive sleepiness, also known as hypersomnia, refers to feelings of extreme fatigue and drowsiness, often leading to involuntary sleep. In mild cases, the patient is aware and can be awakened, but feels extremely fatigued and sleepy; in severe cases, the patient may be in a state of deep sleep, only occasionally responding. Excessive sleepiness is often due to insufficient spirit and Qi. Dampness can obstruct the clear Yang; spleen Qi deficiency can lead to insufficient middle Qi, preventing nourishment of the spirit, leading to excessive sleepiness.
This can be seen in dampness obstructing the spleen or spleen Qi deficiency. If heart and kidney Yang are weak, leading to internal cold and insufficient spirit, it can lead to a state of drowsiness. This can be seen in heart and kidney Yang deficiency. If the spirit is disturbed by pathogens, leading to confusion, it can lead to a state of deep sleep. This can be seen in warm diseases, heat entering the Ying and blood, or pathogens invading the heart. It can also be seen in stroke conditions. After a severe illness, if the spirit is fatigued and the patient is excessively sleepy, it indicates that the righteous Qi has not yet recovered.
(7) Ask about Menstruation and Discharge
Women have physiological characteristics related to menstruation, discharge, pregnancy, and childbirth, which can lead to pathological changes in these areas when diseases occur. Therefore, for female patients after puberty, in addition to general inquiries, it is important to ask about their menstruation and discharge as part of the diagnosis and differentiation.
1. Ask about Menstruation
It is important to inquire about the menstrual cycle, duration, volume, color, quality, and whether there are any symptoms of amenorrhea or menstrual pain.
(1) Menstrual Cycle: This refers to the time interval between each menstrual period, which is normally about 28-32 days. Abnormalities in the menstrual cycle mainly manifest as early menstruation, late menstruation, or irregular menstruation.
Early Menstruation: This refers to the menstrual cycle occurring more than eight or nine days earlier than normal. This is often due to excessive heat in the blood or Qi deficiency.
Late Menstruation: This refers to the menstrual cycle occurring more than eight or nine days later than normal. This is often due to cold in the blood, blood deficiency, or blood stasis.
Irregular Menstruation: This refers to irregular timing of menstruation, with differences of more than eight or nine days. This is often due to emotional distress, leading to liver Qi stagnation, or deficiency of Qi and blood, leading to obstruction of the Chong and Ren meridians, or blood stasis leading to obstruction of the flow of blood, causing irregular menstruation.
(2) Menstrual Volume: This refers to the amount of menstrual bleeding, which is normally about 50 milliliters. Abnormalities in menstrual volume mainly manifest as excessive or insufficient menstrual bleeding.
Excessive Menstrual Bleeding: This refers to menstrual bleeding exceeding 100 milliliters. This is often due to excessive heat in the blood, blood stasis, or Qi deficiency.
Insufficient Menstrual Bleeding: This refers to menstrual bleeding less than 30 milliliters. This is often due to cold congealing, leading to insufficient blood flow, or blood deficiency, leading to insufficient blood generation, or blood stasis, leading to obstruction of menstrual flow.
(3) Abnormal Uterine Bleeding: This refers to irregular vaginal bleeding in women. Clinically, this is most commonly seen in blood heat or Qi deficiency. When blood is heated, it can lead to excessive bleeding, damaging the Chong and Ren meridians, leading to continuous bleeding, often with a rapid onset. Spleen deficiency, leading to descent of middle Qi, or Qi deficiency leading to instability of the Chong and Ren meridians, can also lead to continuous bleeding, often with a slower onset. Additionally, blood stasis can also lead to abnormal uterine bleeding.
(4) Amenorrhea: This refers to women of reproductive age who have not menstruated or have stopped menstruating for more than three months without being pregnant. Amenorrhea can be caused by various reasons, with the pathogenesis generally involving obstruction of the meridians or deficiency of blood. This can be seen in liver Qi stagnation, blood stasis, excessive dampness, Yin deficiency, or spleen deficiency.
Amenorrhea should be distinguished from physiological amenorrhea during pregnancy, lactation, or menopause, as well as temporary amenorrhea due to emotional or environmental changes during puberty or menopause.
(5) Menstrual Pain: This refers to pain in the lower abdomen during menstruation or before and after menstruation. This is often due to obstruction of the meridians, leading to poor circulation of Qi and blood, or insufficient nourishment of the meridians. This can be seen in cold congealing, Qi stagnation, blood stasis, or Qi and blood deficiency. If the pain occurs before menstruation, it often indicates excess; if it occurs after menstruation, it often indicates deficiency. If pressure increases the pain, it often indicates excess; if pressure alleviates the pain, it often indicates deficiency. If heat alleviates the pain, it often indicates cold; if heat does not alleviate the pain or worsens it, it often indicates heat. Cramping pain often indicates cold, while stabbing, dull, or distending pain often indicates blood stasis. Lingering pain often indicates blood stasis, while intermittent pain often indicates Qi stagnation, with distension indicating Qi stagnation and blood stasis. If Qi stagnation is the main issue, distension is often more pronounced than pain; if blood stasis is the main issue, pain is often more pronounced than distension.
2. Ask about Discharge
It is important to inquire about the quantity, color, quality, and odor of the discharge. Discharge that is white, clear, and thin, with no odor, often indicates deficiency or cold conditions. Discharge that is yellow or red, thick, sticky, and foul-smelling often indicates excess or heat conditions. If the discharge is white and abundant, dripping continuously, and clear like mucus, it often indicates cold-dampness descending. If the discharge is yellow, thick, and foul-smelling, it often indicates damp-heat descending. If the white discharge is mixed with blood, it is termed red-white discharge, often indicating liver meridian heat.
(8) Ask about Children
Pediatrics, historically known as “mute medicine,” is not only difficult to inquire about but also may not be accurate. When inquiring about children, if they cannot articulate, it is important to ask their relatives. In addition to general inquiries, it is important to ask about the child’s condition before and after birth, feeding, growth and development, vaccination history, and history of infectious diseases.
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