TCM Diagnosis by Asking - One of the 4 Pillars
Questioning or interviewing a patient during intake covers many topics, including:
- Past medical history
- Origin of the current problem
- Living and environmental conditions
- Current and past emotional issues, including family relationships, partner relationships, work issues etc.
- Eating patterns and Diet
- Specific questions relating to bodily systems
Identification of TCM patterns is done by using paradigms such as the 8 Principles (Ba Gong), Zang Fu organ diagnosis, Channel diagnosis, as well as other paradigms. Patterns can be identified generally as in the 8 Principles, or more specifically as in Zang Fu diagnosis.
Absence of a sign or symptom may, in some cases, be vital to a correct TCM diagnosis, and absence of symptoms are generally not reported by a patient. For example, absence of thirst may indicate a cold condition. Keep in mind that all relevant information is not usually provided by the patient.
Traditionally, there are ten areas of questioning
Common areas of Questioning today:
Questions should be relevant to the patients condition, as not all questions are useful in every situation. Additional questions should be asked based on information provided by the patient as well as what is observed by the practitioner.
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Chills and Fever
Chills and Fever in Exterior Patterns
Chills and fever in an Exterior Pattern (unless they are alternating), an invasion or attack by exogenous pathogenic factors. It is important to distinguish the presence of chills or fever or both. Chills is not only the feeling of Cold, but also having an aversion to Cold. The patient does not want to go outside into the Cold, does not like drafts, and the chills are not alleviated by covering up with blankets. Fever, in this context, is a subjective sensation of heat rather than actual body temperature.
The initial stages of an Exterior diseases is an acute condition, like the flu or common cold. When a patient has an aversion to cold and chills, it usually indicates an invasion of exogenous Wind Cold or exogenous Wind Heat. The patient feels cold because the pathogenic factor blocks circulation of the body's Defensive Qi (Wei Qi), which is impaired from circulating and warming the body. The chills and fever occur simultaneously at the beginning stages of an acute disease because the body is trying to expel the pathogen. This is the pathogenic/evil Qi struggling with the antipathogenic/protective Qi.
Symptoms: chills, aversion to cold, possible fever (especially low grade), usually with body aches, absence of sweating, headache.
Pulse: superficial/floating and tight.
Symptoms: Predominantly fever, with only slight aversion to cold or mild chills. Also thirst, slight or profuse sweating.
Pulse: superficial/floating and rapid.
Alternating Fever and Chills
This is a half external and half internal condition where there is exterior invasion of Wind-Cold or Wind-Heat, but the pathogen has penetrated to a deeper level (Shaoyang) of the body .
Exterior diseases are generally diagnosed according to two paradigms:
- The Six Stages (Taiyang, Shaoyang, etc.)
- The Four Levels (Wei, Qi, Ying, Blood).
Chills and Fever in Interior Patterns
Interior Excess Heat patterns usually present with a persistent high fever and aversion to heat, but no chills. Other symptoms may include profuse sweating, thirst, and a flooding pulse.
Interior Deficient Heat patterns usually present with tidal fever (fever that comes in 'tides', at specific hours of the day, usually in the evening or night). Other symptoms may include night sweats, 5 palm heat (heat or sweating in the palms of the hands, soles of the feet, and the chest), and a red tongue body.
- Chills without fever usually indicates interior Cold from Deficiency of Yang
- If chills are alleviated by covering up with blankets, there will be other symptoms such as cold limbs, and a deep, slow and weak pulse.
- A constant low-grade temperature usually indicates Damp Heat
- Fever in the middle of the night
With an adult: This usually indicates Yin Deficiency, especially if accompanied by Night Sweats
With a child: Retention of Food
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It is usually beneficial to ask a patient about sweating, even if they don't initially volunteer the information.
- Do they sweat easily or excessively, and at what times?
- Do they have spontaneous sweating without exertion?
In Exterior Patterns sweating can indicate:
- Wei Qi (Defensive Qi) is weaker than the pathogenic Qi and can not expel the pathogen.
- When other heat signs are present, it may indicate Exterior Wind Heat. If perspiration breaks the fever, the pathogen has been expelled.
- No sweating is usually an Excess Cold pattern, where cold blocks the pores.
In Interior Patterns sweating is differentiated by:
Time of day
- Day time spontaneous perspiration (without exertion) indicates Yang or Qi Deficiency. Wei Qi can not regulate the pores.
- Night time sweats are usually Yin Deficiency. Relative excess of Heat causes pores to open during the Yin most times.
Area of body
- Sweating on the head is usually Stomach Heat or Damp-Heat
- Oily sweat on forehead may indicate Collapse of Yang
- Sweating only on the arms and/or legs is Stomach and Spleen Deficiency
- Sweating only on hands indicates Lung Qi Deficiency or mental anxiety.
- Sweating over the whole body indicates Lung Qi Deficiency
- Five palm heat (palms of the hands ,soles of the feet, and the chest indicates Yin Deficiency
Condition of illness
- Profuse cold sweat during severe illness indicates Yang Collapse
- Oily sweat on forehead that are not flowing and looks like pearls may indicate imminent death from Yang Collapse
Quality of Sweat
- Oily sweat indicates severe Yang Deficiency
- Yellow sweat indicates Damp Heat
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Head and Body
The Head is where all six Yang channels meet. The three Yang channels of the upper limbs end on the face and the three Yang of the lower limbs begin on face. Yang channels bring the clear Yang to the head and orifices, enabling clear vision, hearing, taste, and smell.
Headache is distinguished according to the onset, time, location, nature of the pain, condition.
- Sudden onset and of short duration indicates exterior attack of Wind cold disturbing the Yang or Qi in the head.
- Chronic headaches are often attributed to an interior condition.
Time of Day
- Daytime headache indicates Qi or Yang Deficiency
- Evening headache indicates Blood or Yin Deficiency
- Occipital headache indicates Taiyang channels (BL, SI). Usually caused by Exterior Wind-Cold or Kidney Deficiency
- Frontal headache indicates Yangming channels (LI, ST). Often caused by Stomach Heat or Blood Deficiency, but can also be caused by exogenous Wind.
- Temporal or parietal headache indicates Shaoyang channels (GB, SJ). Usually caused by exterior Wind-Cold or Wind-Heat in Shaoyang, or Rising Liver Fire affecting Gall Bladder channel.
- Vertex headache indicates Jueyin channels (LIV). Usually caused by Deficient Liver Blood
- Whole head headache usually indicates severe Exterior Wind-Cold, or may indicate mild Deficiency of Blood and Qi.
Nature of Pain
- A heavy sensation is usually due to Dampness or Phlegm
- 'Pain inside the brain' is usually due to Kidney Deficiency
- Distending, throbbing, or bursting pain is usually associated with Ascending Liver Yang
- Fixed pain in one area with a boring sensation into the head is usually due to Blood Stagnation
- Headache with aversion to wind or cold usually indicates Exterior invasion of pathogenic factors
- Headache that is worse with Cold indicates a Cold Pattern
- Headache that is worse with Heat indicates Heat Pattern
- Headache that is worse when fatigued, better when at rest usually indicates Qi Deficiency
Dizziness can be due to Internal Wind, Fire, Phlegm, or Deficiency of Qi and Blood
Internal Wind from Ascending Liver Fire
- Dizziness with loss of balance, often with such signs as tinnitus, headache, nausea, red eyes, wiry pulse, irritability, and other characteristic signs of Ascending Liver Yang
- Mild to severe dizziness with heavy and "foggy" feeling in the head plus other signs e.g. nausea, excessive sputum, slippery pulse. Phlegm obstructs the head, so that the clear Yang cannot ascend.
Qi and Blood Deficiency
- Slight dizziness, worse when fatigued, accompanied by such signs as fatigue, perhaps palpitations and difficulty falling asleep, pale tongue and weak pulse.
Acute Onset of Dizziness
- Indicates an Excess pattern
Gradual Onset or Chronic Dizziness
- Indicates a Deficiency pattern
Pain All Over the Body
- Pain that has sudden onset and is accompanied by chills and fever is due to an invasion of exterior Wind, usually Wind-Cold.
- Pain all over the body with fatigue is usually deficiency of Qi and Blood
- Postpartum women with dull pain usually indicates Deficient Blood
- Postpartum women with severe, fixed or stabbing pain usually indicates Blood Stasis
- Muscle pain with hot sensation is usually due to Stomach Heat
- Pain with a feeling of heaviness is usually due to Dampness obstructing the muscles
Pain in the Joints, Painful Obstruction Syndrome (Bi Syndrome)
- Wandering Bi Pain is usually from wind.
- Fixed and very painful joints that are worse in cold weather and improved with heat indicates Cold Bi.
- Fixed pain with numbness and heaviness that is worse when Damp outside indicates Damp Bi.
- Joint pain with swelling and heat in joints may indicate Wind Cold and Damp have turned to heat.
- Continuous dull pain that is better with rest indicates Kidney Deficiency
- Severe pain and stiffness with recent onset indicates lumbar sprain caused by Blood Stasis
- Severe pain that is worse in cold and damp but improved by heat indicates an invasion of exogenous Cold and Damp into the channels of the back.
- Fixed and boring pain and an inability to turn at the waist indicates Blood Stasis
- Pain that extends up to the shoulders, with other exterior symptoms such as headache, stiff neck, nasal congestion, etc. indicates exterior Wind attack.
- Bilateral numbness of the hands and feet, or arms and legs, usually indicates Blood deficiency
- Numbness of fingers (especially the 1st 3 digits), numbness of the elbow and arm on one side is usually internal Wind and Phlegm (impending Wind-stroke).
Thorax and Abdomen
Areas of the thorax and abdomen can be generally associated with the internal organs
||Heart and Lungs, Upper Jiao
|Flanks and Ribcage:
||Liver and Gallbladder
||Liver, Intestines, Spleen, Kidney, Bladder
||Spleen and Stomach
- Chest Pain is often Blood Stasis in the Heart from Deficient Yang.
- Chest Pain with Cough and copious Yellow Phlegm indicates Phlegm-Heat in Lung.
- Distention or Discomfort in the hypochondriac region is usually Liver Qi Stagnation.
- Severe hypochondriac pain is usually indicative of Liver Blood Stasis.
- Can be due to Liver Qi Stagnation or Stomach Heat.
- If the pain is dull, it may indicate retention of food in the stomach.
- If the pain is better after eating or applying heat it may indicate Deficient Cold in Stomach.
- If the pain is worse after eating it may indicate a Deficient pattern.
- If there is also fullness in the epigastrium, this indicates an Excess pattern
Lower Abdominal Pain
- If relieved by defecation, this indicates Excess
- If worse on defecation, this indicates Deficiency
- Internal Cold
- Stagnation of Liver Qi
- Stagnation of Liver Blood
- Retention of food in Intestines
- Blood Stasis in the Intestines
- Blood Stasis in the Uterus
- Damp Heat in Intestines
- Can be caused by Damp-Heat in the Bladder.
- Can be caused by Liver Fire coursing down into the Bladder.
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Food and Taste
This gives us information regarding the state of Spleen & Stomach (also the flavors desired give clues to other Organs according to the five element correspondences).
Appetite and Eating
- Condition relieved by eating indicates a Deficiency pattern
- Condition aggravated by eating indicates an Excess pattern
- Lack of appetite indicates Deficient Spleen Qi
- Always hungry even after eating indicates Stomach Heat
- Fullness/distention after eating indicates Retention of Food
- Prefers warm food indicates a Cold Pattern
- Prefers cold food indicates a Heat Pattern
Taste in Mouth
- Bitter taste is usually due to an Excess Heat pattern (Liver or Heart)
- A constant bitter taste in the mouth is usually due to Liver Fire
- A bitter taste in the morning after no sleep is usually due to Heart Fire
- A sweet taste may indicate Spleen Deficiency or Damp Heat
- A sour taste is usually due to retention of food in Stomach or the Liver invading the Stomach
- A salty taste is usually due to Kidney Yin Deficiency
- A pungent taste is usually due to Lung Heat
- Sour vomiting may indicate Liver Invading Stomach
- Clear/Watery vomiting may indicate Cold in Stomach with Fluid retention
- Vomiting after eating may indicate a Heat Pattern
- Sudden & Loud vomiting may indicate Excess pattern
- Slow & Weak vomiting may indicate Deficiency pattern
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Stools and Urine
A condition alleviated after bowel movement indicates an Excess condition, while a condition worsening after bowel movement indicate a Deficiency condition.
- Acute constipation with infrequent dry stools, accompanied by thirst, and a dry yellow tongue coating indicates heat in stomach and intestines
- Constipation in elderly, or women postpartum indicates Deficient Blood and Fluids
- Constipation with small, bitty stools indicates Liver Qi Stagnation and Heat in Intestines
- Difficult bowel movements with stools that are not dry indicates Liver Qi Stagnation
- Constipation with abdominal pain indicates Internal Cold and Yang Deficiency or Liver Qi Stagnation
- Constipation with dry stools and no thirst indicates Kidney or Stomach Yin Deficiency
- Alternating constipation and diarrhea indicates Liver Qi invading the Spleen
- With pain indicates Stagnation of Liver Qi, or Liver Heat, or interior Heat or Cold in the Intestines
- Foul odor, especially if urgent indicates Heat
- Urgent diarrhea or loose stools with burning sensation in the anus indicates Heat
- Absence of odor indicates Cold
- Chronic diarrhea indicates Deficient Kidney or Spleen Yang failing to transform food and fluid
- Chronic, daily, and early morning (cocks crow diarrhea) indicates Kidney Yang Deficiency
- With mucous indicates Dampness in the Intestines
- Frequent watery or unformed stools indicates Deficient Yang, Deficient Qi, or Dampness
- Loose stools with undigested food indicates Deficient Spleen Qi or Deficient spleen Yang
- Frequent or urgent stools that are not loose or only slightly loose indicates Sinking of Spleen Qi or Spleen and Stomach Qi Deficiency
- Black or very dark stools indicates Blood Stagnation
- With Blood indicates a Heat condition (A patient with Blood in the stool should always be referred to a western physician to rule out Cancer)
Borborygmus (gurgling in the abdomen)
- With loose stools indicates Spleen deficiency
- With abdominal distention but no loose stool indicates Liver Qi Stagnation
- Stagnation of Liver Qi is often involved
- With foul odor indicates Damp-Heat in Spleen, Stomach Heat, or Stagnant Qi in the Small Intestine
- Without odor indicates Deficient Spleen Yang producing interior Cold
- Enuresis/incontinence indicates Kidney Yang Deficiency
- Retention of urine indicates Damp Heat in Bladder
- Difficult urination, especially with painful and dark urine, indicates Damp-Heat in Bladder
- Inability to complete urination, dribbling, or lack of force in urination indicates Kidney Qi Deficiency, Dampness, or Cold
- Frequent and copious urination, especially at night, indicates Kidney Yang Deficiency
- Frequent and scanty urination indicates Kidney Qi deficiency
- Frequent, scanty, and dark urination indicates Damp-Heat in Bladder
Pain associated with urination
- Before urination indicates Stagnation of Qi in the Lower Jiao
- During urination indicates Heat in Bladder
- After urination indicates Deficiency of Qi
- Pale indicates Cold of the Bladder and Kidney, usually from deficient Kidney Yang
- Dark, yellow, or reddish indicates Heat
- Turbid or Cloudy indicates Dampness in bladder
- Large amounts indicates Kidney Yang Deficiency
- Scanty amount indicates Heat or Dampness obstructing Bladder, Deficient Fluids, or Kidney Yin Deficiency producing Empty Heat
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The Heart is the residence of the Shen, and the Blood and Yin nourish the Shen. When Blood and/or Yin is Deficient, the Shen has no residence and can not rest.
- Unable to fall asleep but sleeps well once asleep is usually due to Deficient Heart Blood
- Waking often during night is usually Heat disturbing the Shen
This can be due to Kidney Yin failing to nourish Heart Yin, Stomach Heat from retention of food, etc.
- Waking early or unable to fall asleep again indicates Gallbladder Deficiency. This is common in the elderly as Qi and Blood are weaker.
- Dream-disturbed sleep usually indicates Liver Fire and/or Heart Fire
Liver Fire and Heart Fire can be due to Kidney Yin Deficiency
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Ears and Eyes
The Kidney opens to the ears, but not all ear disorders are related to the Kidney. The Shaoyang channels (GB, SJ) travel to the ears, and some Exterior Heat conditions that affect the Shaoyang can cause ear problems.
Dampness and Phlegm can also obstruct rising of Yang to upper orifices which can affect the ears.
Tinnitus (Ringing in the Ears)
- Sudden onset indicates Excess condition, usually of Liver Fire or Liver Wind
- Gradual onset indicates Kidney Deficiency
- Aggravated by pressing on ears indicates Excess
- Alleviated by pressing on ears indicates Deficiency
- Loud, high pitched noise like whistle indicates Rising Liver Yang, Liver Fire, or Liver Wind
- Low pitched noise like rushing water indicates Kidney Deficiency
- Sudden onset indicates Excess condition, usually Liver Fire or Liver Wind
- Gradual onset and chronic deafness indicates Deficiency, usually of the Kidney, or of Heart Blood Deficiency, or Yang Deficiency
- Pain, swelling, and redness indicates Invasion by Exogenous Wind-Heat or internal Liver Fire
- Blurry vision and floaters indicates Liver Blood Deficiency
- Photophobia indicates Liver Blood Deficiency
- Pressure in eyes indicates Kidney Yin Deficiency and/or Liver Fire
- Dryness of eyes indicates Liver/Kidney Yin Deficiency
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Thirst ad Drink
- For cold liquids indicates Heat
- For warm liquids indicates Cold
- Thirst for large amounts of Cold Water indicates an Excess Heat Pattern
- No Thirst indicates Cold pattern, usually of the Stomach or Spleen
- Thirst with no desire to drink indicates Damp-Heat
- Thirst with desire to sip liquids slowly, or sip warm liquids indicates Yin Deficiency (of Stomach or Kidney)
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Excess conditions causing pain are usually due to Qi circulation in the Channels being obstructed due to stagnation, cold, or heat.
Deficient condition that cause pain are usually due to the channels not being nourished by Yin and Blood. An
Excess condition causes more severe pain, while a deficient one causes more dull pain.
- Invasion of exogenous pathogens
- Interior Cold or Heat
- Stagnation of Qi (causes distention more than pain, or vague distending sensation without location)
- Stasis of Blood, usually causes severe, localized, fixed, or boring pain
- Obstruction by Phlegm
- Retention of Food
- Deficient Qi and Blood
- Deficient Yin with consumption of Body Fluids
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Ask about Menstruation, Vaginal Discharge, Pregnancy, and Childbirth.
A Woman's menses give a clear idea of the condition of her Qi and Blood.
- Amount of bleeding
- Quality of flow
- Pain or other symptoms, before, during and after flow
- Early arrival of period indicates Heat in the Blood (red tongue) or Qi Deficiency (pale tongue)
- Late period indicates Blood Deficiency, Blood Stagnation, or Cold
- Irregular period indicates Stagnation of Liver Qi or Deficient Spleen Qi
- Heavy blood loss that is bright red indicates Heat in Blood, while pale and more scanty blood indicates Spleen Qi Deficiency
- Abnormal Uterine Bleeding indicates Heat in Blood, Deficient Spleen Qi, Stagnant Qi or congealed Blood, or Deficient Liver/Kidney Yin
- Scanty periods indicates Blood Deficiency or Stagnation of Blood or Cold Obstructing
- Amenorrhea indicates Deficient Blood and Qi, Stagnant Qi/Blood Stasis, Deficient Kidney/Liver Yin, Mucus dampness Obstructing Menses
- Normal color is a dull to medium red
- Very dark red or bright red Indicates Heat in the Blood
- Pale blood Indicates Deficiency of Blood
- Purple/blackish blood Indicates Stasis of Blood or Cold
- Congealed blood with clots Indicates Blood stasis or Cold
- Watery blood Indicates Blood or Yin Deficiency
- Turbid blood Indicates Blood Heat or Stagnation of Cold
- Before periods indicates Stagnation of Qi or Blood, Cold/Cold Damp Obstructing
- During periods indicates Stagnation of Qi or Blood, Stagnation of Cold, or Deficient Blood and Qi
- After periods indicates Qi and Blood Deficiency
- White, thin, clear indicates Cold from Spleen or Kidney Yang Deficiency, Exogenous Cold Damp, or Stagnation of Liver Qi
- Yellow, especially if thick and accompanied by vaginal itching or soreness indicates Damp-Heat in the Lower Jiao
- Red and white discharge indicates Damp Heat
- Yellow, with pus and blood after menopause indicates Toxic Damp-Heat in the Uterus (the patient should be referred to a western physician for a complete gynecological exam)
- Watery indicates Cold Damp
- Thick indicates Damp Heat
- Little or no odor indicates Cold
- Strong odor indicates heat
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Pregnancy and Childbirth
- Infertility due to Deficiency is usually because of Deficient Blood, Deficient Kidney Jing, or Cold
- Infertility due to Excess is usually because of Damp Heat in Lower Burner or Stasis of Blood in Uterus
- Vomiting during pregnancy indicates Stomach Heat, or Deficiency of Stomach and Chong Mai
- Miscarriage before three months may indicate Deficiency of Blood or Essence (Kidney)
- Miscarriage after three months may indicate Stasis of Liver Blood or Sinking of Spleen Qi
- Nausea and heavy bleeding after delivery indicates Exhaustion of Chong Mai
- Sweating and fever after delivery indicates Exhaustion of Qi and Blood
- Postnatal depression may indicate Blood Deficiency has lead to Heart Blood Deficiency