TCM Diagnosis by Looking (Observation) - One of the 4 Pillars

TCM Diagnosis by Looking (Observation) - One of the 4 Pillars

What is observed by the Practioner.

Shen (Spirit)

Observing and tuning in to a patient's Shen (spirit) is particularly important to help determine the overal state and prognosis of an imbalance. The Shen gives vital imformation about vitality, and mental, emotional, and spiritual well being. The Shen shows in the eyes, complexion, and state of mind.

Body (appearance)

The Five Elements can be associated with body shapes and constitutions

  • Wood Type
    Slender and tall body shape
  • Fire Type
    Pointed head and chin, small hands, with curly or a small amount of hair
  • Metal Type
    Square and broad shoulders, strong body type, and a triangle shaped face
  • Earth Type
    Large head, larger body and belly, strong legs, and a wide jaw
  • Water Type
    Round face and body with a longer than normal torso

Long Term Body Changes

  • Emaciated, body, esp. with dry skin
    Deficient Blood or Yin
  • Very large thighs
    Spleen Deficiency
  • Great weight loss over course of long illness
    Essential Qi exhausted
  • Overweight
    Deficient Spleen Qi with tendency to Dampness or Phlegm (often with Stagnation of Qi)
  • Hair loss
    Kidney Jing Deficiency or Blood Deficiency
  • Musculoskeletal pain, soreness, numbness or heaviness with swelling and restricted movement
    Bi Syndrome (Painful Obstruction syndrome)
  • Gradual onset of weakness, motor impairment, and muscular atrophy of the limbs:
    Wei Syndromes (flaccidity syndrome)

Short term bodily changes

  • Change in Muscles (e.g. flaccid, wasting)
    Spleen disharmony
  • Change in Tendons (e.g. stiffness, weakness)
    Liver disharmony
  • Change in Blood Vessels (hardening, producing hard pulse)
    Heart disharmony
  • Change in skin (e.g. tone, dryness
    Lung disharmony
  • Change in bones (e.g. brittle)
    Kidney disharmony

Appearance and Demeanor

Includes posture and movement of body as a whole and of individual parts, e.g. eyes, face, mouth, limbs, fingers.

Symptom(s) Cause or Pattern
Overweight with Mental Depression Qi Xu and Excess Damp Phlegm
Loss of Weight in Long Term Illness Exhaustion of Essential Qi
Thin with Dry Skin Blood Xu
Extended Neck Excess Lung Syndrome with Excess Phlegm
Facing Downward Qi Xu with Shortness of Breath, Dislike of Speaking
Violent Movement of Limbs Wind Diseases, Infantile Convulsions
Weakness, Motor Impairment, and Muscular Atrophy of Limbs Wei Syndromes
Pain, Soreness, Heaviness and Numbness in Tendons, Bones and Muscles, with Swelling and Restricted Movement of Joints Bi Syndromes
Numbness or Impaired Movement of Limbs on One Side of the Body Hemiplegia or Wind Stroke
Active patient with excessive/jerky movement: Yang, Excess or Heat patterns
Passive manner or lack of movement/slow movement: Yin, deficient, Cold
Continuous fidgeting, especially of legs: Deficient Kidney Yin
Tremors, convulsions (of whole body or localized): Interior Liver Wind

Head and Face


  • Hair relates to Blood or Kidney Jing.
  • Hair loss and premature graying of the hair may be due to Blood Deficiency or Kidney Jing Deficiency.
  • Dandruff usually relates to Liver Blood or Yin Deficiency


  • Two light and shallow lines between the eyebrows indicates a healthy Liver.
  • Two deep lines or three line between the eyebrows can indicate a Liver problem, such as frequent anger
  • A single line can indicate a more serious Liver problem. This can occur after considerable hardship.

Face Color

  • Represents the strength of the Qi and Blood of the Zang Fu organs, and especially the Heart.
  • The complexion should be moist and lustrous.
Red (Excess or Xu Heat)
Whole Face Heat from External Evil or Hyperactivity of Zang Fu (Excess)
Cheeks, Tidal Fever, Night Sweats Internal Heat (Xu)
Pale (Cold or Loss of Blood)
Pale White Yin Excess or Yang Xu
Bright White with Puffy and Bloated Appearance Yang Qi Xu
Withered White Blood Xu
Yellow (Damp or Xu)
Body, Face, Eyes, and Skin Jaundice
Bright Orange Yang Jaundice (Damp Heat)
Smoky Dark Yin Jaundice (Cold Damp or Long Term Stagnation)
Pale Yellow (Not Bright) Blood and Qi Xu
Blue (Cold, Pain, Blood Stagnation, Convulsions)
Pale with Blue Tinge and Severe Pain in the Epigastrium and Abdomen Excess Yin and Cold
Bluish Purple Face and Lips with Intermittent Pain Behind the Sternum or Precordial Region Stagnation of Heart Blood
Bluish Purple Face and Lips with High Fever and Violent Movement of Limbs in Children Infantile Convulsion
Dark Gray (Blood Stagnation and Kidney Xu)
Pale and Dark with Lumbar Soreness and Cold Feet Kidney Yang Xu
Dark without Brightness with Scaly Skin Prolonged Blood Stagnation

Observation of Sense Organs


The eyes reflect the state of the Shen and Jing. It is said, "The Jing of the five Yin and six Yang organs ascends to the eyes." We observe the "expression" of the eyes to see the spirit.

The Liver opens to the eyes (sense organ associated with Wood element)
Eyesight changes tend to relate to the Liver

Symptom(s) Cause or Pattern
Shining and are Clear Good vitality of Shen & Jing
Redness and Swelling Wind Heat or Liver Fire
Yellow Sclera Jaundice
Ulceration or Canthus Damp Heat
Upward, Straight Forward, or Sideways Staring Liver Wind
Dull or Clouded eyes Disturbed Shen, weakened Jing. Commonly seen in drug users and long term emotional problems
Nystagmus Disturbance of Liver Wind
Spots in visual field: Deficiency of Liver Blood or Kidney Yin or Jing
Swelling or dark rings under eyes: Deficiency of Kidney


Symptom(s) Cause or Pattern
Tip of the Nose Relates to Spleen and Stomach
Flapping of Ala Nasi Heat in the Lungs or Qi Xu of both Lung and Kidney
Clear Discharge Wind Cold
Turbid Discharge Wind Heat
Prolonged Turbid Discharge, with Stinking Discharge Rhinitis or Chronic Sinusitis

Mouth and Lips

Color, moisture and appearance. Normal color is pale red, moist and shiny

Symptom(s) Cause or Pattern
Pale Lips Blood Xu
Bluish Purple Lips Retention of Cold or Blood Stagnation
Red and Dry Lips Excess Heat
Breathing through mouth Lung Qi Deficiency
Mouth always slightly open Deficiency
Sudden Collapse with Open Mouth Xu
Sudden Collapse with Lockjaw Excess
Greenish around mouth Liver Blood Stasis or Liver invading Spleen

Teeth and Gums

Teeth are considered an extension of bone and are influenced by Kidneys. Gums are influenced by the Stomach.

Symptom(s) Cause or Pattern
Moist teeth Good Fluids, and healthy Kidneys
Pale Gums Blood Xu
Redness and Swelling of Gums Stomach Fire
Redness and Swelling of gums with Bleeding Injury of Vessels by Stomach Fire


Symptom(s) Cause or Pattern
Redness, Swelling, and Soreness Lung and Stomach Heat
Redness and Swelling with Yellow or White Ulcer Spots Toxic Heat in Lung and Stomach
Slightly sore, dry, red, not swollen, chronic condition Deficient Kidney Yin
Bright Red with Mild Soreness Yin Xu with Hyperactive Fire
False Gray and White Membrane over Throat that is Hard to Remove, and Bleeds Following Removal Diphtheria from Heat in the Lung Consuming Yin.


Observe color, discharge, skin tone, any spots or discoloration.

Symptom(s) Cause or Pattern
Burnt Black and Dry and Withered Auricles in Severe Illness Consumption of Kidney essence
Purulent Discharge Damp Heat of Liver and Gall Bladder


Flesh around wrists and ankles should be a good color and firm: indicates a good condition of the fluids.

Symptom(s) Cause or Pattern
Dry, dull skin on wrists/ankles with withered flesh Exhausted Fluids
Thenar eminence State of Stomach
Bluish color of venules on thenar eminence Cold in Stomach
Red venules Heat in Stomach


Symptom(s) Cause or Pattern
Pale Blood Deficiency
Bluish Liver or Heart Blood Stasis
Split Liver Blood Deficiency

Digital Venule Examination in Children

Examine the venules on the index finger in children under 2.

Use left index finger in boys and right in girls.
Creases in joints of index fingers are called "gates".

  • Wind Gate
    First, crease at mcp articulation
  • Qi Gate
    Second (1st interphalangeal)
  • Life Gate
    Third (distal interphalangeal)

Method: rub finger towards body. Venules may appear.

If venules are only present beyond the Gate of Wind, this indicates mild disease (invasion by exterior pathogen). If venules extend beyond Gate of Qi: interior, more severe condition. If venules extend beyond Gate of Life: serious, life-threatening condition. Bluish venules indicate a Cold pattern whereas red venules indicate aHeat pattern


  • Skin relates to the Lungs in Five Element Theory.
  • Skin also indicates the condition of the Blood (and therefore the Liver, which stores Blood).
  • Many skin conditions relate to Heat in the Blood or stasis of Blood and may relate to Liver.
  • Skin disease can also relate to Heat in the Stomach which can cause Blood Heat.


  • Dry skin
    Often indicates Deficient Blood
  • Itchy skin
  • Pitting edema
    Kidney Yang Deficiency

Venules (spider veins) on the skin are exterior manifestation of the superficial channels. They are often seen behind the knees or around ankles in older people.

Venule Color Cause or Pattern
Red Heat
Bluish Cold
Greenish Pain
Purple Blood Stasis

References Used

The TCM information presented here has been referenced from numerous sources; including teachers, practitioners, class notes from Five Branches University, the following books, as well as other sources. If you have benefited from this information, please consider supporting the authors and their works by purchasing the books below.

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